APPLICATION for MATERNAL and NEWBORN DESIGNATION
Bed Capacity/Services

SERVICES

See 105 CMR 130.020	
TOTAL NUMBER OF BEDS/BASSINETS PER SERVICE	
NUMBER OF BEDS/BASSINETS PER UNIT/NURSERY	
LOCATION (BLDG.,/WING, FLOOR, UNIT, CAMPUS – If applicable)	(If applicable)
NUMBER OF BEDS TEMPORARILY OUT-OF-SERVICE (INCLUDED IN LICENSED BED CAPACITY)

(Identify month/day/year out-of-service)	COMMENTS	

MATERNAL SERVICE 
(Specify type):
     ANTEPARTUM

     POSTPARTUM

     LDRP
     (LABOR-DELIVERY-  
     RECOVERY-POST-  
     PARTUM)						

NEONATAL INTENSIVE CARE UNIT   

WELL INFANT NURSERY

CONTINUING CARE NURSERY (CCN)

SPECIAL CARE NURSERY (SCN)

SERVICES
	
TOTAL NUMBER  OF BAYS	
LOCATION (BLDG.,/WING, FLOOR, UNIT, CAMPUS – If applicable)	
COMMENTS	
LABOR ROOMS

LABOR-DELIVERY-RECOVERY ROOMS

C-SECTION ROOMS

DELIVERY ROOMS

RECOVERY ROOMS