Menu
PRISM
Log In
Username
Password
Forgot Password?
Remember me on this device.
Security Info
New User?
Create A New Account.
Search
Search
About PRISM
Mission
Staff
Organization Chart
Career Center
PRISM Captive - Affiliate Risk Captive
Captive Website
PRISM ARC Travel Reimbursement Form 2025
News
Blog
PRISM Fast Facts
PRISM Long Term Strategic Goals & Milestones
Transparency
EAGLE Awards
EAGLE Award Winners 2024
EAGLE Award Winners 2023
EAGLE Award Winners 2022
EAGLE Award Winners 2021
EAGLE Award Winners 2020
EAGLE Award Winners 2019
EAGLE Award Winners 2018
EAGLE Award Winners 2017
Coverages
Property & Casualty
General Liability 1
General Liability 2
Primary Workers' Compensation
Excess Workers' Compensation
Medical Malpractice
Property
Master Rolling Owner Controlled Insurance Program
Miscellaneous Coverages
Employee Benefits
PRISM Employee Benefits Symposium
PRISMHealth
Dental
Paid Family Leave
Ancillary Coverages
Managing a Hard Market
Governance
Board of Directors
Membership
Agendas
Summaries
Claims Review
Membership
Agendas
Summaries
Claims Review 2
Membership
Agendas
Summaries
Employee Benefits
Membership
Agendas
Summaries
Executive
Membership
Agendas
Summaries
Finance
Membership
Agendas
Summaries
General Liability 2
Membership
Agendas
Summaries
Governance Sub-Committee
Agendas
Membership
Legislative
Membership
Agendas
Summaries
Medical Malpractice
Membership
Agendas
Summaries
Contract Bank
Member Services
Membership
Agendas
Summaries
Personnel Sub-Committee
Membership
Primary Workers' Compensation
Membership
Agendas
Summaries
PRISMHealth
Membership
Agendas
Summaries
Property
Membership
Agendas
Summaries
Technology
Membership
Agendas
Summaries
Underwriting
Membership
Agendas
Summaries
Members
County
Public Entity
City
County
County Ops
Educational
IHSS
Special Districts
Affiliates
City
County
County Ops
Educational
IHSS
Special Districts
Participants
City
County
County Ops
Educational
IHSS
Special Districts
Calendar
Upcoming Meetings and Events
Year-At-A-Glance
Resources
ELink
Coming Soon!
Law Enforcement Resources
POST Certified Courses
First Responder Program (ConcernPlus)
STC Certified Course
Additional Resources
PRISM Perspectives Podcast
Education Connection
PRISM Message Board
Legislation
Bills of Interest
PRISM Legislative Platform
Legislative Links
PRISM Documents
PRISM Glossary and Terms
Member Job Opportunities
COVID-19 Resources
Services
Risk Management
Risk Control
Training
Toolbox
Partner Programs
Claims
Analytics
Analytics Dashboards
Data Quality Assistance
Loss Data
Loss Data Requirements and Resources
Upload Loss Data
Loss Data Collection Authorization
Contact
Vendors
Alliant Insurance Services
Responsibility
Alpha Listing
Industry Associations
Infectious Disease / Vector Reporting, Monitoring and Control Duties
Toggle navigation
MedMal
Facility Business Address
Address
City
State
Zip
Mailing Address
Address
City
State
Zip
Please select any of the Facility Types that are applicable to the exposures you are reporting in this application:
Does this application include information for a Hospital or Medical Center?
Does this application include information for a Public Health Clinic or are Public Health Services provided?
Does this application include information for a Mental Health Clinic or are Mental Health services provided?
Does this application include information for a Jail, Juvenile Hall, or other Correctional Care Facilities?
Does this application include information for a School or provide Student Care Services?
Please check all the Facility Sub-Types that apply to the exposures you are reporting in this application:
General Hospital
Teaching Hospital
Medical School
Critical Access Hospital (CAH)
How many cesarean sections (previous 12 months)?
How many vaginal births after c-section (VBACs) (previous 12 months)?
Is continuous electronic fetal monitoring performed on all patients in active labor?
If no, please explain:
Do nurse midwives practice at your hospital?
Is the facility a regional referral center for high risk pregnancies or newborns requiring intensive care?
If no, does a written procedure exist for transferring all high-risk mothers and/or babies which the hospital is not qualified to treat?
Level I: Well baby
Well Baby/Number of bassinets:
Level II: Intermediate care
Intermediate Care/Number of bassinets:
Level III: Neonatal intensive care
Neonatal/Number of bassinets:
Sex change operations
Weight reduction surgery
Laser assisted surgery
Are "scope" surgical procedures routinely videotaped?
Employed Physicians
Outside Surgeons
Residents
Are sponge, needle and instrument counts performed in the course of a surgical procedure?
If yes, at what intervals of operation?
Neurosurgery
Experimental surgery
Interns
Does the facility utilize the unit dose system of dispensing medicine?
Is the pharmacy for patient use only?
If No, annual receipts for non-patients medications are:
Is the pharmacy staffed by a contract group?
Elected Officials
Appointed Officials
Volunteers
Full Time Employees
Part Time Employees
Full-Time Equivalents (FTE)
Board Members
Certified
Classified
Administrative
Total Number of Employees
If the prior employee total differs from the amount provided previously by more than 10%, please provide reasons for the change.
K-8 ADA
9-12 ADA
Adult Education ADA
Total ADA
As the prior average daily attendance differs from the amount provided previously by more than 10%, please provide reasons for the change
Firefighters
Police/Sheriff
Peace Officers
Other
Other Description
Do you have events where 250+ volunteers will be working on behalf of your organization
If Yes, please provide details of the event(s)
WC Budgeted Payroll
Upload Submember Payroll
Aircraft Operation (7424)(1)
Airport Law Enforcement Officers (7720)
Airport Operator (7429)
Animal Control Officers (7720)
Bus Operators (7382)
Clerical Office (8810)
Clerical Telecommuting Employees (8871)
County Probation Officers, Group Counselors, or Juvenile Services Officers (9410)
District Attorney Inspectors (9410)
Electrical Light or Power Line Construction (7538)
Electrical Light or Power Companies (7539)
Firefighters - Regular (7706)
Harbor or Port Police Officers (7720)
Hospitals (9043)
Hospitals - veterinary (8831)(1)
Housing Authorities (9033)
Institutional (8830)
Libraries (8812)
Lifeguards (9420)
Medical Center Employees (8834)
Municipal - Non-Manual Labor (9410)
Municipal - Manual Labor (9420)
Museum Curators (8838)
Home
Resources
Questions
MedMal
Infectious Disease / Vector Reporting, Monitoring and Control Duties
Resources
Infectious Disease / Vector Reporting, Monitoring and Control Duties