American College of Hyperbaric Medicine
Where Wound Healing Begins
Applicant Contact
Applicant Name
Applicant Email
Phone
Facility Information
Facility Name
Address
Primary Contact (Name, Title, Email, Phone)
Chamber Type MonoplaceMultiplace
Scope of Services
Leadership & Governance
Safety Director (Name & Credentials)
Team Roster (attach license copies)
Executive Sign-off (Name & Title)
Training & Competency
ACHM-approved training certificates (attach)
Annual competency assessments documented? [radio* annual-assessments use_label_element "Yes" "No"]
Staff participation in ACHM education (describe / attach if needed)
Additional training files (optional)
Clinical Standards & Safety Protocols
PPP Adoption Policy
Chamber Operations Manual
Emergency Response Plan
Safety Procedures
Quality & Outcomes
Evidence-based outcome data (healing rates, adverse events)
CQI Plan
Patient-safety incident reporting framework
Site Accreditation Readiness
Preliminary self-assessment
Leadership commitment statement
Attestation
By signing below, I affirm the information is accurate and complete and that this facility commits to upholding ACHM safety standards.
Signature (type full legal name)
Date
[acceptance* consent] I agree to the above attestation and to be contacted regarding this application.
