Triage Specialist Course Application

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

• Letter of Recommendation
  
  Please provide the name, contact number, and email address of your supervisor (Nurse Manager or higher), who will be contacted by Triage First and asked to provide a letter of recommendation.
  
  Supervisor's First Name
  
  
  Supervisor's Last Name
  
  
  Supervisor's Contact Number
  
  
  Supervisor'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.