Applications will be processed as they are received, and applicants will be notified soon after as to whether the application has been accepted.
Application
Please complete the following carefully. You will be contacted as soon as possible for further information.
Items marked with an asterisk (*) are required.
First Name *
Last Name *
Physical Address
Address 1 *
Address 2
City *
State *
Zip Code *
Mailing Address (if different from above)
Address 1
Address 2
City
State
Zip Code
Employer Address
Employer (Organization) Name *
Address 1 *
Address 2
City *
State *
Zip Code *
Contact Information
Email Address *
Home Phone *
Work Phone *
Cell Phone
What is the best method of inital contact for you?
Email
Home Phone
Work Phone
Cell Phone
What time of day is best?
Morning
Afternoon
Evening
Any time
Current Position/Title *
Number of Years in Nursing *
Number of Years in ED Nursing *
Number of Years Triage Experience *
Certifications Held (with expiration dates of each)
If applicable, when and where did you attend the Triage First Comprehensive ED Triage Course?
Month
Year
City
Size of Facility (visits per annum)
10,000
10,000-20,000
20,000-40,000
40,000-60,000
60,000-80,000
> 80,000
Does your facility have a pediatric department?
Yes
No
What triage acuity scale does your department use?
Modified Canadian Triage Acuity Scale (CTAS)
Emergency Severity Index (ESI)
Other:
Triage Specialist Course you would like to attend:
November 14-19, 2010
April 3-8, 2011
How did you hear about the Triage Specialist Course?
What are your motivations or reasons for participating in this course?
What is your view of the role of the triage nurse in the emergency department?
What is the most significant challenge to implementing change in your ED?
Additional Requirements