Please complete the following carefully. You will be contacted as soon as possible for further information. There are a limited number of spaces available for each course. Participant acceptance will be based on a combination of factors. 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)


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?
Canadian Triage Acuity Scale (CTAS)
Emergency Severity Index (ESI)
Other:

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

• Letter of Recommendation
  
  Please provide the name, contact number, and email address of your ED nurse manager, who will be contacted by Triage First and asked to provide a letter of recommendation.
  
  Nurse Manager's First Name
  
  
  Nurse Manager's Last Name
  
  
  Nurse Manager's Contact Number
  
  
  Nurse Manager's Email Address
  
  
  
• Mail photocopies of certification cards (both sides copied) to:
  Triage First, Inc.
  P.O. Box 1924
  Fairview, NC 28730
  Or fax them to the attention of "Triage Specialist Course" at (828) 628-8025.