Name


Email Address


Employer


Phone


Employer Address (Street)


City


State


Zip Code


In which department do you work?
Emergency Department Trauma Services Administration Education Other

What best describes your position/title?
Nurse Manager Physician Team Leader Administration Other

What is your hospital's census this year?
10,000 - 15,000 16,000 - 20,000 21,000 - 25,000 26,000 - 30,000 31,000 - 40,000 41,000 - 50,000 51,000 - 60,000 61,000 - 75,000 76,000 - 100,000 > 100,000

What is your emergency department's census this year?


What percentage of increase in ED census is expected in the next three years?
1% - 2% 3% - 4% 5% +

Number of beds in your ED


Number of RNs


Number of Techs


What are the primary concerns for your department?
Overall Patient Flow
Triage and Patient Disposition
Staffing patterns
Ancillary services
Patient Satisfaction
Design and/or re-design of the ED
Teamwork

In just a few words, what is the biggest challenge facing you in your position?


What other comments would you like to make regarding the needs of your ED?


What time frame are you considering for changes in your ED?
As soon as possible 3 - 6 months 7 - 12 months Over 1 year

How did you hear about Triage First's services?
Referred by colleague Attended workshop Through the web Magazine advertising Brochure Other