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?
Nurse Manager Physician Team Leader Administration Staff Nurse 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 type(s) of education program is most needed? (You may choose more than one.)
Clinical Skills
Patient Throughput
Teamwork
5-Acuity Implementation
Patient Satisfaction
Documentation
Safety Issues
Triage Concepts
Gang Violence
Psychiatric Triage
Domestic Violence
Leadership and Management Skills
Other:

What triage acuity scale is currently in use in your emergency department?
Canadian Triage Acuity Scale (CTAS)
Emergency Severity Index (ESI)
Three Level Acuity
Four Level Acuity
Unknown
We would like to discuss that - it's part of our issue here

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


How many staff would you expect to attend?


What time frame are you considering?
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