redcap.dellmed.utexas.edu
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https://redcap.dellmed.utexas.edu/surveys/?s=RY95Ty5WVbVHTq5y
Submission: On August 23 via manual from US
Submission: On August 23 via manual from US
Form analysis 9 forms found in the DOM
Name: form — POST /surveys/index.php?s=RY95Ty5WVbVHTq5y
<form action="/surveys/index.php?s=RY95Ty5WVbVHTq5y" enctype="multipart/form-data" target="_self" method="post" name="form" id="form"><input type="hidden" name="redcap_csrf_token" value="">
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<span id="maxchecked_tag_label" class="" style="display:none;z-index:1000;">Cannot select choice! The maximum number of choices has been selected.</span><span id="matrix_rank_remove_label" class="opacity75" style="display:none;">Value
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<div id="questiontable_loading" style="display: none; visibility: visible;">
<img alt="Loading..." src="/redcap_v11.2.4/Resources/images/progress_circle.gif"> Loading...
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<table role="presentation" class="form_border container-fluid" style="display: table;" id="questiontable">
<tbody class="formtbody">
<tr id="intake_pecc-sh-tr" sq_id="{}" style="display: table-row;">
<td class="header toolbar" colspan="3">We would like to begin by learning a bit more about you.</td>
</tr>
<tr id="intake_pecc-tr" sq_id="intake_pecc" req="1">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_pecc" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Do you consider yourself a pediatric champion or a Pediatric Emergency Care Coordinator (PECC)?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><input name="intake_pecc" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-intake_pecc">
<div class="choicevert"><input type="radio" id="opt-intake_pecc_1" tabindex="0" name="intake_pecc___radio" aria-labelledby="label-intake_pecc label-intake_pecc-1"
onclick="document.forms['form'].intake_pecc.value=this.value;doBranching('intake_pecc');" value="1"> <label id="label-intake_pecc-1" for="opt-intake_pecc_1" class="mc">Yes</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_pecc_0" tabindex="0" name="intake_pecc___radio" aria-labelledby="label-intake_pecc label-intake_pecc-0"
onclick="document.forms['form'].intake_pecc.value=this.value;doBranching('intake_pecc');" value="0"> <label id="label-intake_pecc-0" for="opt-intake_pecc_0" class="mc">No</label></div>
<div class="resetLinkParent d-print-none"><a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('intake_pecc','form');return false;">reset</a></div>
<div id="intake_pecc_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_pecc_research-tr" sq_id="intake_pecc_research" req="1" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_pecc_research" aria-hidden="true">
<div class="rich-text-field-label">
<div dir="ltr">
<div dir="ltr">
<div><span style="font-weight: normal;">We are currently conducting a survey to characterize the pediatric champion or PECC position across the nation. </span>Would you be willing to comple an additional survey<span
style="font-weight: normal;"> to help better define the pediatric champion/PECC role in the future and assist with creating standards?</span></div>
<div> </div>
<div><span style="font-weight: normal;">This should take approximately </span>15 minutes to complete.</div>
</div>
</div>
<p><br><br></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><input name="intake_pecc_research" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-intake_pecc_research">
<div class="choicevert"><input type="radio" id="opt-intake_pecc_research_1" tabindex="0" name="intake_pecc_research___radio" aria-labelledby="label-intake_pecc_research label-intake_pecc_research-1"
onclick="document.forms['form'].intake_pecc_research.value=this.value;" value="1"> <label id="label-intake_pecc_research-1" for="opt-intake_pecc_research_1" class="mc">Yes</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_pecc_research_0" tabindex="0" name="intake_pecc_research___radio" aria-labelledby="label-intake_pecc_research label-intake_pecc_research-0"
onclick="document.forms['form'].intake_pecc_research.value=this.value;" value="0"> <label id="label-intake_pecc_research-0" for="opt-intake_pecc_research_0" class="mc">No</label></div>
<div class="resetLinkParent d-print-none"><a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('intake_pecc_research','form');return false;">reset</a></div>
<div id="intake_pecc_research_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_yrs_experience-tr" sq_id="intake_yrs_experience" req="1" style="display: table-row;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_yrs_experience" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">How many years have you been providing care for patients in an emergency setting?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><span><select role="listbox" aria-required="true" aria-labelledby="label-intake_yrs_experience" class="x-form-text x-form-field " name="intake_yrs_experience" tabindex="0">
<option value=""></option>
<option value="1">< 1 year</option>
<option value="2">1-5 years</option>
<option value="3">5-10 years</option>
<option value="4">10-15</option>
<option value="5">15-20 years</option>
<option value="6">> 20 years</option>
<option value="7">I do not provide direct clinical care</option>
</select></span>
<div id="intake_yrs_experience_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_yrs_current-tr" sq_id="intake_yrs_current" req="1">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_yrs_current" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">How many years have you been working at your current organization?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><span><select role="listbox" aria-required="true" aria-labelledby="label-intake_yrs_current" class="x-form-text x-form-field " name="intake_yrs_current" tabindex="0">
<option value=""></option>
<option value="1">< 1 year</option>
<option value="2">1-5 years</option>
<option value="3">5-10 years</option>
<option value="4">10-15</option>
<option value="5">15-20 years</option>
<option value="6">> 20 years</option>
</select></span>
<div id="intake_yrs_current_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_ped_train-tr" sq_id="intake_ped_train" req="1">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_ped_train" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Do you have any specialized training in pediatric care?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><input name="intake_ped_train" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-intake_ped_train">
<div class="choicevert"><input type="radio" id="opt-intake_ped_train_1" tabindex="0" name="intake_ped_train___radio" aria-labelledby="label-intake_ped_train label-intake_ped_train-1"
onclick="document.forms['form'].intake_ped_train.value=this.value;doBranching('intake_ped_train');" value="1"> <label id="label-intake_ped_train-1" for="opt-intake_ped_train_1" class="mc">Yes</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_ped_train_0" tabindex="0" name="intake_ped_train___radio" aria-labelledby="label-intake_ped_train label-intake_ped_train-0"
onclick="document.forms['form'].intake_ped_train.value=this.value;doBranching('intake_ped_train');" value="0"> <label id="label-intake_ped_train-0" for="opt-intake_ped_train_0" class="mc">No</label></div>
<div class="resetLinkParent d-print-none"><a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('intake_ped_train','form');return false;">reset</a></div>
<div id="intake_ped_train_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="in_ped_train_spec-tr" sq_id="in_ped_train_spec" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-in_ped_train_spec" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Please describe your pediatric training.</span></p>
</div>
</label></td>
<td class="data col-5"> <textarea autocomplete="new-password" class="x-form-field notesbox" aria-labelledby="label-in_ped_train_spec" id="in_ped_train_spec" name="in_ped_train_spec" tabindex="0"></textarea>
<div id="in_ped_train_spec-expand" class="expandLinkParent d-print-none">
<a href="javascript:;" tabindex="-1" class="expandLink" onclick="growTextarea('in_ped_train_spec')">Expand</a>
</div>
<div id="in_ped_train_spec_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_ce-tr" sq_id="intake_ce" req="1">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_ce" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Are you planning to apply for continuing education or maintenance of certification credit as part of your participation in this collaborative?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><input name="intake_ce" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-intake_ce">
<div class="choicevert"><input type="radio" id="opt-intake_ce_1" tabindex="0" name="intake_ce___radio" aria-labelledby="label-intake_ce label-intake_ce-1" onclick="document.forms['form'].intake_ce.value=this.value;" value="1"> <label
id="label-intake_ce-1" for="opt-intake_ce_1" class="mc">Yes</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_ce_0" tabindex="0" name="intake_ce___radio" aria-labelledby="label-intake_ce label-intake_ce-0" onclick="document.forms['form'].intake_ce.value=this.value;" value="0"> <label
id="label-intake_ce-0" for="opt-intake_ce_0" class="mc">No</label></div>
<div class="resetLinkParent d-print-none"><a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('intake_ce','form');return false;">reset</a></div>
<div id="intake_ce_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_pedsreday-tr" sq_id="intake_pedsreday" req="1">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_pedsreday" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">How familiar are you with the concept of pediatric readiness and/or the National Pediatric Readiness Project?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><span><select role="listbox" aria-required="true" aria-labelledby="label-intake_pedsreday note-intake_pedsreday" class="x-form-text x-form-field " name="intake_pedsreday" tabindex="0">
<option value=""></option>
<option value="1">Not at all familiar</option>
<option value="2">Somewhat familiar</option>
<option value="3">Familiar</option>
<option value="4">Very familiar</option>
<option value="5">Extremely familiar</option>
</select></span>
<div id="intake_pedsreday_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
<div id="note-intake_pedsreday" class="note" aria-hidden="true">Visit https://emscimprovement.center/domains/pediatric-readiness/ to learn more.</div>
</td>
</tr>
<tr id="intake_qi-tr" sq_id="intake_qi" req="1">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_qi" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Please select the best descriptor of your knowledge of quality improvement (QI) methodology.</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><span><select role="listbox" aria-required="true" aria-labelledby="label-intake_qi" class="x-form-text x-form-field " name="intake_qi" tabindex="0">
<option value=""></option>
<option value="1">I am completely new to QI</option>
<option value="2">I have heard some of the QI concepts (drivers, change strategies, etc) but have never used it</option>
<option value="3">I have a very basic working knowledge of QI</option>
<option value="4">I regularly use QI methods in my daily work</option>
<option value="5">I would consider myself an expert in QI (e.g., hold certifications such as CPHQ, CPPS)</option>
</select></span>
<div id="intake_qi_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_sp_goal-tr" sq_id="intake_sp_goal" req="1" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_sp_goal" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Which of the following is of highest priority for your EMSC program regarding PECCs?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><span><select role="listbox" aria-required="true" aria-labelledby="label-intake_sp_goal" class="x-form-text x-form-field " name="intake_sp_goal" onchange="clean_datetime(this,'');doBranching('intake_sp_goal');"
tabindex="0">
<option value=""></option>
<option value="1">Develop a marketing strategy to promote PECCs</option>
<option value="2">Develop a network of PECCs</option>
<option value="3">Develop education program for PECCs</option>
<option value="4">Develop a PECC certification program</option>
<option value="5">Developing a PECC requirement in Pediatric Recognition Programs (ED and EMS)</option>
<option value="6">Other</option>
</select></span>
<div id="intake_sp_goal_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_sp_goalother-tr" sq_id="intake_sp_goalother" req="1" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_sp_goalother" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">You selected "other" above. Please describe your EMSC program's highest priority for PECCs.</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"> <textarea autocomplete="new-password" class="x-form-field notesbox" aria-labelledby="label-intake_sp_goalother" id="intake_sp_goalother" name="intake_sp_goalother" tabindex="0"></textarea>
<div id="intake_sp_goalother-expand" class="expandLinkParent d-print-none">
<a href="javascript:;" tabindex="-1" class="expandLink" onclick="growTextarea('intake_sp_goalother')">Expand</a>
</div>
<div id="intake_sp_goalother_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_takeaway-tr" sq_id="intake_takeaway" req="1">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_takeaway" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">What do you hope to take away from this collaborative?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"> <textarea autocomplete="new-password" class="x-form-field notesbox" aria-labelledby="label-intake_takeaway" id="intake_takeaway" name="intake_takeaway" tabindex="0"></textarea>
<div id="intake_takeaway-expand" class="expandLinkParent d-print-none">
<a href="javascript:;" tabindex="-1" class="expandLink" onclick="growTextarea('intake_takeaway')">Expand</a>
</div>
<div id="intake_takeaway_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_other-tr" sq_id="intake_other">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_other" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Is there anything else that you would like us to know about you?</span></p>
</div>
</label></td>
<td class="data col-5"> <textarea autocomplete="new-password" class="x-form-field notesbox" aria-labelledby="label-intake_other" id="intake_other" name="intake_other" tabindex="0"></textarea>
<div id="intake_other-expand" class="expandLinkParent d-print-none">
<a href="javascript:;" tabindex="-1" class="expandLink" onclick="growTextarea('intake_other')">Expand</a>
</div>
<div id="intake_other_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_ed_name-sh-tr" sq_id="{}" style="display: table-row;">
<td class="header toolbar" colspan="3">This section will inform us of you organizational structure.</td>
</tr>
<tr id="intake_ed_name-tr" sq_id="intake_ed_name" req="1" style="display: table-row;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_ed_name" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Please select your ED from the following list.</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><span><select role="listbox" aria-required="true" aria-labelledby="label-intake_ed_name" class="x-form-text x-form-field rc-autocomplete rc-autocomplete-enabled" name="intake_ed_name" style="">
<option value=""></option>
<option value="35237">Banner Ironwood Medical Center</option>
<option value="other">Other, please specify below.</option>
</select></span>
<div class="nowrap" style="max-width:95%;"><input role="combobox" tabindex="0" type="text" class="x-form-text x-form-field rc-autocomplete ui-autocomplete-input" id="rc-ac-input_intake_ed_name" aria-labelledby="label-intake_ed_name"
autocomplete="off" style="width: 254px;"><button listopen="0" tabindex="-1" onclick="return false;" class="ui-button ui-widget ui-state-default ui-corner-right rc-autocomplete" aria-label="Click to view choices"><img
class="rc-autocomplete" src="/redcap_v11.2.4/Resources/images/arrow_state_grey_expanded.png" alt="Click to view choices"></button></div>
<div id="intake_ed_name_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_agency_name-tr" sq_id="intake_agency_name" req="1" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_agency_name" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Please select you EMS agency.</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><span><select role="listbox" aria-required="true" aria-labelledby="label-intake_agency_name" class="x-form-text x-form-field rc-autocomplete rc-autocomplete-enabled" name="intake_agency_name" style="">
<option value=""></option>
<option value="other">Other, please specify below.</option>
</select></span>
<div class="nowrap" style="max-width:95%;"><input role="combobox" tabindex="0" type="text" class="x-form-text x-form-field rc-autocomplete ui-autocomplete-input" id="rc-ac-input_intake_agency_name"
aria-labelledby="label-intake_agency_name" autocomplete="off" style="width: 220px;"><button listopen="0" tabindex="-1" onclick="return false;" class="ui-button ui-widget ui-state-default ui-corner-right rc-autocomplete"
aria-label="Click to view choices"><img class="rc-autocomplete" src="/redcap_v11.2.4/Resources/images/arrow_state_grey_expanded.png" alt="Click to view choices"></button></div>
<div id="intake_agency_name_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="org_name_other-tr" sq_id="org_name_other">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-org_name_other" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">If you cannot find your organizaiton above, please enter it here.</span></p>
</div>
</label></td>
<td class="data col-5"> <input autocomplete="new-password" aria-labelledby="label-org_name_other" class="x-form-text x-form-field " type="text" name="org_name_other" value="" tabindex="0">
<div id="org_name_other_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="total_volume-tr" sq_id="total_volume" req="1" style="display: table-row;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-total_volume" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">What is the annual </span>total<span style="font-weight: normal;"> (adult and pediatric) patient volume of your ED?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><span><select role="listbox" aria-required="true" aria-labelledby="label-total_volume" class="x-form-text x-form-field " name="total_volume" tabindex="0">
<option value=""></option>
<option value="1">Low: < 10,000 patients per year</option>
<option value="2">Medium: 10,000-49,999 patients per year</option>
<option value="3">Medium to High: 50,000-74,999 patients per year</option>
<option value="4">High: >= 75,000 patients per year</option>
</select></span>
<div id="total_volume_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intakte_prehospital_volume-tr" sq_id="intakte_prehospital_volume" req="1" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intakte_prehospital_volume" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Approximately how many </span>total<span style="font-weight: normal;"> </span>calls<span style="font-weight: normal;"> (both adult and pediatric) does your organization respond to annually?</span>
</p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"> <input autocomplete="new-password" aria-required="true" aria-labelledby="label-intakte_prehospital_volume note-intakte_prehospital_volume" class="x-form-text x-form-field " type="text"
name="intakte_prehospital_volume" value="" tabindex="0">
<div id="note-intakte_prehospital_volume" class="note" aria-hidden="true">Numeric data only, e.g., 5000, not "five thousand"</div>
<div id="intakte_prehospital_volume_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_ed_pedvol-tr" sq_id="intake_ed_pedvol" req="1" style="display: table-row;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_ed_pedvol" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">What is the annual </span>pediatric<span style="font-weight: normal;"> patient volume in your ED?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><span><select role="listbox" aria-required="true" aria-labelledby="label-intake_ed_pedvol note-intake_ed_pedvol" class="x-form-text x-form-field " name="intake_ed_pedvol" tabindex="0">
<option value=""></option>
<option value="1">Low: < 1800 pediatric patients (average of 5 or fewer a day)</option>
<option value="2">Medium: 1,800-4,999 pediatric patients (average of 6-13 a day)</option>
<option value="3">Medium to High: 5,000-9,999 pediatric patients (average of 14-26 a day)</option>
<option value="4">High: >= 10,000 pediatric patients (average of 27 or more a day)</option>
</select></span>
<div id="intake_ed_pedvol_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
<div id="note-intake_ed_pedvol" class="note" aria-hidden="true">Pediatric as defined by your organization. If no definition exists, use 0-18 years</div>
</td>
</tr>
<tr id="intake_ems_pedvol-tr" sq_id="intake_ems_pedvol" req="1" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_ems_pedvol" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">What is the annual number of </span>pediatric<span style="font-weight: normal;"> calls your organization respond to</span><span style="font-weight: normal;">?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><span><select role="listbox" aria-required="true" aria-labelledby="label-intake_ems_pedvol note-intake_ems_pedvol" class="x-form-text x-form-field " name="intake_ems_pedvol" tabindex="0">
<option value=""></option>
<option value="1">Low: < 12 pediatric calls in the last year (1 or fewer per month)</option>
<option value="2">Medium 13-100 pediatric calls in the last year (1-8 pediatric calls per month)</option>
<option value="3">Medium to High: 101-600 pediatric calls in the last year (8-50 pediatric calls per month)</option>
<option value="4">High: >= 600 pediatric calls in the last year (more than 50 pediatric calls per month)</option>
</select></span>
<div id="intake_ems_pedvol_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
<div id="note-intake_ems_pedvol" class="note" aria-hidden="true">Pediatric as defined by your organization. If no definition exists, use 0-18 years</div>
</td>
</tr>
<tr id="intake_urbanicity-tr" sq_id="intake_urbanicity" req="1" style="display: table-row;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_urbanicity" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Please select the descriptor that best applies to your service area: </span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><input name="intake_urbanicity" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-intake_urbanicity">
<div class="choicevert"><input type="radio" id="opt-intake_urbanicity_1" tabindex="0" name="intake_urbanicity___radio" aria-labelledby="label-intake_urbanicity label-intake_urbanicity-1"
onclick="document.forms['form'].intake_urbanicity.value=this.value;" value="1"> <label id="label-intake_urbanicity-1" for="opt-intake_urbanicity_1" class="mc">Remote / Tribal</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_urbanicity_2" tabindex="0" name="intake_urbanicity___radio" aria-labelledby="label-intake_urbanicity label-intake_urbanicity-2"
onclick="document.forms['form'].intake_urbanicity.value=this.value;" value="2"> <label id="label-intake_urbanicity-2" for="opt-intake_urbanicity_2" class="mc">Rural</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_urbanicity_3" tabindex="0" name="intake_urbanicity___radio" aria-labelledby="label-intake_urbanicity label-intake_urbanicity-3"
onclick="document.forms['form'].intake_urbanicity.value=this.value;" value="3"> <label id="label-intake_urbanicity-3" for="opt-intake_urbanicity_3" class="mc">Suburban</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_urbanicity_4" tabindex="0" name="intake_urbanicity___radio" aria-labelledby="label-intake_urbanicity label-intake_urbanicity-4"
onclick="document.forms['form'].intake_urbanicity.value=this.value;" value="4"> <label id="label-intake_urbanicity-4" for="opt-intake_urbanicity_4" class="mc">Urban</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_urbanicity_5" tabindex="0" name="intake_urbanicity___radio" aria-labelledby="label-intake_urbanicity label-intake_urbanicity-5"
onclick="document.forms['form'].intake_urbanicity.value=this.value;" value="5"> <label id="label-intake_urbanicity-5" for="opt-intake_urbanicity_5" class="mc">None of these apply</label></div>
<div class="resetLinkParent d-print-none"><a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('intake_urbanicity','form');return false;">reset</a></div>
<div id="intake_urbanicity_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_descriptor-tr" sq_id="intake_descriptor" req="1" style="display: table-row;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_descriptor" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Which of the following best describes your organization?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><input name="intake_descriptor" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-intake_descriptor">
<div class="choicevert"><input type="radio" id="opt-intake_descriptor_1" tabindex="0" name="intake_descriptor___radio" aria-labelledby="label-intake_descriptor label-intake_descriptor-1"
onclick="document.forms['form'].intake_descriptor.value=this.value;" value="1"> <label id="label-intake_descriptor-1" for="opt-intake_descriptor_1" class="mc">Critical Access</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_descriptor_2" tabindex="0" name="intake_descriptor___radio" aria-labelledby="label-intake_descriptor label-intake_descriptor-2"
onclick="document.forms['form'].intake_descriptor.value=this.value;" value="2"> <label id="label-intake_descriptor-2" for="opt-intake_descriptor_2" class="mc">County</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_descriptor_3" tabindex="0" name="intake_descriptor___radio" aria-labelledby="label-intake_descriptor label-intake_descriptor-3"
onclick="document.forms['form'].intake_descriptor.value=this.value;" value="3"> <label id="label-intake_descriptor-3" for="opt-intake_descriptor_3" class="mc">Community</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_descriptor_4" tabindex="0" name="intake_descriptor___radio" aria-labelledby="label-intake_descriptor label-intake_descriptor-4"
onclick="document.forms['form'].intake_descriptor.value=this.value;" value="4"> <label id="label-intake_descriptor-4" for="opt-intake_descriptor_4" class="mc">Academic Medical Center</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_descriptor_5" tabindex="0" name="intake_descriptor___radio" aria-labelledby="label-intake_descriptor label-intake_descriptor-5"
onclick="document.forms['form'].intake_descriptor.value=this.value;" value="5"> <label id="label-intake_descriptor-5" for="opt-intake_descriptor_5" class="mc">Children's Hospital</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_descriptor_6" tabindex="0" name="intake_descriptor___radio" aria-labelledby="label-intake_descriptor label-intake_descriptor-6"
onclick="document.forms['form'].intake_descriptor.value=this.value;" value="6"> <label id="label-intake_descriptor-6" for="opt-intake_descriptor_6" class="mc">None of these apply</label></div>
<div class="resetLinkParent d-print-none"><a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('intake_descriptor','form');return false;">reset</a></div>
<div id="intake_descriptor_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_pmrp-tr" sq_id="intake_pmrp" req="1" style="display: table-row;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_pmrp" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Does your organization participate in a pediatric medical recognition program?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><input name="intake_pmrp" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-intake_pmrp">
<div class="choicevert"><input type="radio" id="opt-intake_pmrp_1" tabindex="0" name="intake_pmrp___radio" aria-labelledby="label-intake_pmrp label-intake_pmrp-1" onclick="document.forms['form'].intake_pmrp.value=this.value;" value="1">
<label id="label-intake_pmrp-1" for="opt-intake_pmrp_1" class="mc">Yes</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_pmrp_0" tabindex="0" name="intake_pmrp___radio" aria-labelledby="label-intake_pmrp label-intake_pmrp-0" onclick="document.forms['form'].intake_pmrp.value=this.value;" value="0">
<label id="label-intake_pmrp-0" for="opt-intake_pmrp_0" class="mc">No</label></div>
<div class="resetLinkParent d-print-none"><a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('intake_pmrp','form');return false;">reset</a></div>
<div id="intake_pmrp_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_sp_pmrp-tr" sq_id="intake_sp_pmrp" req="1" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_sp_pmrp" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Does your state have an established pediatric medical recognition program for either EMS agencies or hospitals?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><input name="intake_sp_pmrp" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-intake_sp_pmrp">
<div class="choicevert"><input type="radio" id="opt-intake_sp_pmrp_1" tabindex="0" name="intake_sp_pmrp___radio" aria-labelledby="label-intake_sp_pmrp label-intake_sp_pmrp-1"
onclick="document.forms['form'].intake_sp_pmrp.value=this.value;" value="1"> <label id="label-intake_sp_pmrp-1" for="opt-intake_sp_pmrp_1" class="mc">Yes</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_sp_pmrp_0" tabindex="0" name="intake_sp_pmrp___radio" aria-labelledby="label-intake_sp_pmrp label-intake_sp_pmrp-0"
onclick="document.forms['form'].intake_sp_pmrp.value=this.value;" value="0"> <label id="label-intake_sp_pmrp-0" for="opt-intake_sp_pmrp_0" class="mc">No</label></div>
<div class="resetLinkParent d-print-none"><a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('intake_sp_pmrp','form');return false;">reset</a></div>
<div id="intake_sp_pmrp_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="ed_intake_network-tr" sq_id="ed_intake_network" req="1" style="display: table-row;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-ed_intake_network" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Is your organization part of a hospital network or system?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><input name="ed_intake_network" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-ed_intake_network">
<div class="choicevert"><input type="radio" id="opt-ed_intake_network_1" tabindex="0" name="ed_intake_network___radio" aria-labelledby="label-ed_intake_network label-ed_intake_network-1"
onclick="document.forms['form'].ed_intake_network.value=this.value;doBranching('ed_intake_network');" value="1"> <label id="label-ed_intake_network-1" for="opt-ed_intake_network_1" class="mc">Yes</label></div>
<div class="choicevert"><input type="radio" id="opt-ed_intake_network_0" tabindex="0" name="ed_intake_network___radio" aria-labelledby="label-ed_intake_network label-ed_intake_network-0"
onclick="document.forms['form'].ed_intake_network.value=this.value;doBranching('ed_intake_network');" value="0"> <label id="label-ed_intake_network-0" for="opt-ed_intake_network_0" class="mc">No</label></div>
<div class="resetLinkParent d-print-none"><a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('ed_intake_network','form');return false;">reset</a></div>
<div id="ed_intake_network_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_network_name-tr" sq_id="intake_network_name" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_network_name" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Name of Network</span></p>
</div>
</label></td>
<td class="data col-5"> <input autocomplete="new-password" aria-labelledby="label-intake_network_name" class="x-form-text x-form-field " type="text" name="intake_network_name" value="" tabindex="0">
<div id="intake_network_name_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_ed_config-tr" sq_id="intake_ed_config" req="1" style="display: table-row;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_ed_config" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Which one of the following is the best description of your ED configuration for the care of pediatric patients?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><input name="intake_ed_config" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-intake_ed_config">
<div class="choicevert"><input type="radio" id="opt-intake_ed_config_1" tabindex="0" name="intake_ed_config___radio" aria-labelledby="label-intake_ed_config note-intake_ed_config label-intake_ed_config-1"
onclick="document.forms['form'].intake_ed_config.value=this.value;doBranching('intake_ed_config');" value="1"> <label id="label-intake_ed_config-1" for="opt-intake_ed_config_1" class="mc">Pediatric ED in a Children's Hospital
(hospital cares ONLY for children)</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_ed_config_2" tabindex="0" name="intake_ed_config___radio" aria-labelledby="label-intake_ed_config note-intake_ed_config label-intake_ed_config-2"
onclick="document.forms['form'].intake_ed_config.value=this.value;doBranching('intake_ed_config');" value="2"> <label id="label-intake_ed_config-2" for="opt-intake_ed_config_2" class="mc">Separate pediatric ED in a general hospital
(adult and children within one hospital)</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_ed_config_3" tabindex="0" name="intake_ed_config___radio" aria-labelledby="label-intake_ed_config note-intake_ed_config label-intake_ed_config-3"
onclick="document.forms['form'].intake_ed_config.value=this.value;doBranching('intake_ed_config');" value="3"> <label id="label-intake_ed_config-3" for="opt-intake_ed_config_3" class="mc">General ED (pediatric and adult patients seen
in the same area)</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_ed_config_4" tabindex="0" name="intake_ed_config___radio" aria-labelledby="label-intake_ed_config note-intake_ed_config label-intake_ed_config-4"
onclick="document.forms['form'].intake_ed_config.value=this.value;doBranching('intake_ed_config');" value="4"> <label id="label-intake_ed_config-4" for="opt-intake_ed_config_4" class="mc">Stand-by ED (physician on call)</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_ed_config_5" tabindex="0" name="intake_ed_config___radio" aria-labelledby="label-intake_ed_config note-intake_ed_config label-intake_ed_config-5"
onclick="document.forms['form'].intake_ed_config.value=this.value;doBranching('intake_ed_config');" value="5"> <label id="label-intake_ed_config-5" for="opt-intake_ed_config_5" class="mc">Free-standing ED (ED unattached to a hospital
with inpatient services)</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_ed_config_6" tabindex="0" name="intake_ed_config___radio" aria-labelledby="label-intake_ed_config note-intake_ed_config label-intake_ed_config-6"
onclick="document.forms['form'].intake_ed_config.value=this.value;doBranching('intake_ed_config');" value="6"> <label id="label-intake_ed_config-6" for="opt-intake_ed_config_6" class="mc">Other</label></div>
<div class="resetLinkParent d-print-none"><a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('intake_ed_config','form');return false;">reset</a></div>
<div id="intake_ed_config_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
<div id="note-intake_ed_config" class="note" aria-hidden="true">pediatric as defined by your hospital</div>
</td>
</tr>
<tr id="intake_ed_config_other-tr" sq_id="intake_ed_config_other" req="1" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_ed_config_other" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">You marked "other" to the previous question. </span></p>
<p><span style="font-weight: normal;">Please describe your ED configuration for the care of children</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"> <input autocomplete="new-password" aria-required="true" aria-labelledby="label-intake_ed_config_other" class="x-form-text x-form-field " type="text" name="intake_ed_config_other" value="" tabindex="0">
<div id="intake_ed_config_other_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="hospital_designations-tr" sq_id="hospital_designations" req="1" style="display: table-row;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-hospital_designations" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Please select all designations that apply to your hospital :</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5">
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-hospital_designations label-hospital_designations-1" tabindex="0" onchange="clean_datetime(this,'');doBranching('hospital_designations');"
id="id-__chk__hospital_designations_RC_1" name="__chkn__hospital_designations" code="1" onclick="checkboxClick('hospital_designations','1',this,event,0);"><input type="hidden" value="" name="__chk__hospital_designations_RC_1"> <label
id="label-hospital_designations-1" class="mc" for="id-__chk__hospital_designations_RC_1">STEMI/ACS</label></div>
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-hospital_designations label-hospital_designations-2" tabindex="0" onchange="clean_datetime(this,'');doBranching('hospital_designations');"
id="id-__chk__hospital_designations_RC_2" name="__chkn__hospital_designations" code="2" onclick="checkboxClick('hospital_designations','2',this,event,0);"><input type="hidden" value="" name="__chk__hospital_designations_RC_2"> <label
id="label-hospital_designations-2" class="mc" for="id-__chk__hospital_designations_RC_2">Stroke Center</label></div>
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-hospital_designations label-hospital_designations-3" tabindex="0" onchange="clean_datetime(this,'');doBranching('hospital_designations');"
id="id-__chk__hospital_designations_RC_3" name="__chkn__hospital_designations" code="3" onclick="checkboxClick('hospital_designations','3',this,event,0);"><input type="hidden" value="" name="__chk__hospital_designations_RC_3"> <label
id="label-hospital_designations-3" class="mc" for="id-__chk__hospital_designations_RC_3">American College of Surgeons Committee on Trauma (ACS-COT) verified Trauma Center</label></div>
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-hospital_designations label-hospital_designations-4" tabindex="0" onchange="clean_datetime(this,'');doBranching('hospital_designations');"
id="id-__chk__hospital_designations_RC_4" name="__chkn__hospital_designations" code="4" onclick="checkboxClick('hospital_designations','4',this,event,0);"><input type="hidden" value="" name="__chk__hospital_designations_RC_4"> <label
id="label-hospital_designations-4" class="mc" for="id-__chk__hospital_designations_RC_4">State verified Trauma Center</label></div>
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-hospital_designations label-hospital_designations-5" tabindex="0" onchange="clean_datetime(this,'');doBranching('hospital_designations');"
id="id-__chk__hospital_designations_RC_5" name="__chkn__hospital_designations" code="5" onclick="checkboxClick('hospital_designations','5',this,event,0);"><input type="hidden" value="" name="__chk__hospital_designations_RC_5"> <label
id="label-hospital_designations-5" class="mc" for="id-__chk__hospital_designations_RC_5">Other</label></div>
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-hospital_designations label-hospital_designations-6" tabindex="0" onchange="clean_datetime(this,'');doBranching('hospital_designations');"
id="id-__chk__hospital_designations_RC_6" name="__chkn__hospital_designations" code="6" onclick="checkboxClick('hospital_designations','6',this,event,0);"><input type="hidden" value="" name="__chk__hospital_designations_RC_6"> <label
id="label-hospital_designations-6" class="mc" for="id-__chk__hospital_designations_RC_6">None</label></div>
<div class="space"></div>
<div id="hospital_designations_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="ed_intake_acs_trauma-tr" sq_id="ed_intake_acs_trauma" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-ed_intake_acs_trauma" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Trauma Center - ACS-COT Designated Level</span></p>
</div>
</label></td>
<td class="data col-5"><span><select role="listbox" aria-labelledby="label-ed_intake_acs_trauma" class="x-form-text x-form-field " name="ed_intake_acs_trauma" tabindex="0">
<option value=""></option>
<option value="1">Level 1</option>
<option value="2">Level 2</option>
<option value="3">Level 3</option>
<option value="4">Pediatric Level 1</option>
<option value="5">Pediatric Level 2</option>
</select></span>
<div id="ed_intake_acs_trauma_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="ed_intake_state_trauma-tr" sq_id="ed_intake_state_trauma" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-ed_intake_state_trauma" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Trauma Center - State Designated Level</span></p>
</div>
</label></td>
<td class="data col-5"><span><select role="listbox" aria-labelledby="label-ed_intake_state_trauma" class="x-form-text x-form-field " name="ed_intake_state_trauma" tabindex="0">
<option value=""></option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
</select></span>
<div id="ed_intake_state_trauma_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="hospital_designations_other-tr" sq_id="hospital_designations_other" req="1" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-hospital_designations_other" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">You marked "other" to the previous question. </span></p>
<p><span style="font-weight: normal;">Please describe the other designation that applies to your hospital.</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"> <input autocomplete="new-password" aria-required="true" aria-labelledby="label-hospital_designations_other" class="x-form-text x-form-field " type="text" name="hospital_designations_other" value="" tabindex="0">
<div id="hospital_designations_other_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="ed_intake_pedsready-tr" sq_id="ed_intake_pedsready" req="1" style="display: table-row;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-ed_intake_pedsready" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Has your emergency department completed the 2021 National Pediatric Readiness Assessment?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><input name="ed_intake_pedsready" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-ed_intake_pedsready">
<div class="choicevert"><input type="radio" id="opt-ed_intake_pedsready_1" tabindex="0" name="ed_intake_pedsready___radio" aria-labelledby="label-ed_intake_pedsready note-ed_intake_pedsready label-ed_intake_pedsready-1"
onclick="document.forms['form'].ed_intake_pedsready.value=this.value;" value="1"> <label id="label-ed_intake_pedsready-1" for="opt-ed_intake_pedsready_1" class="mc">Yes</label></div>
<div class="choicevert"><input type="radio" id="opt-ed_intake_pedsready_0" tabindex="0" name="ed_intake_pedsready___radio" aria-labelledby="label-ed_intake_pedsready note-ed_intake_pedsready label-ed_intake_pedsready-0"
onclick="document.forms['form'].ed_intake_pedsready.value=this.value;" value="0"> <label id="label-ed_intake_pedsready-0" for="opt-ed_intake_pedsready_0" class="mc">No</label></div>
<div class="resetLinkParent d-print-none"><a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('ed_intake_pedsready','form');return false;">reset</a></div>
<div id="ed_intake_pedsready_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
<div id="note-ed_intake_pedsready" class="note" aria-hidden="true">Visit https://www.pedsready.org for more information on the National Pediatric Readiness Assessment.</div>
</td>
</tr>
<tr id="ed_intake_pedsready_score-tr" sq_id="ed_intake_pedsready_score" style="display: table-row;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-ed_intake_pedsready_score" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Please enter you most recent pediatric readiness score, if available</span></p>
</div>
</label></td>
<td class="data col-5"> <input autocomplete="new-password" aria-labelledby="label-ed_intake_pedsready_score note-ed_intake_pedsready_score" class="x-form-text x-form-field " type="text" name="ed_intake_pedsready_score" value=""
onblur="redcap_validate(this,'','100','soft_typed','number',1)" tabindex="0" fv="number">
<div id="note-ed_intake_pedsready_score" class="note" aria-hidden="true">Your nurse manager should have this information</div>
<div id="ed_intake_pedsready_score_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_ems_certlevel-tr" sq_id="intake_ems_certlevel" req="1" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_ems_certlevel" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">What is the highest level of certification of your EMS agency?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><span><select role="listbox" aria-required="true" aria-labelledby="label-intake_ems_certlevel" class="x-form-text x-form-field " name="intake_ems_certlevel" tabindex="0">
<option value=""></option>
<option value="1">Basic Life Support (BLS)</option>
<option value="2">Intermediate Life Support (ILS)</option>
<option value="3">Advanced Life Support (ALS)</option>
</select></span>
<div id="intake_ems_certlevel_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_licensure-tr" sq_id="intake_licensure" req="1" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_licensure" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">What is the highest level of licensure that pertains to the scope of care that EMS providers in your agency provide to patients?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><span><select role="listbox" aria-required="true" aria-labelledby="label-intake_licensure" class="x-form-text x-form-field " name="intake_licensure" tabindex="0">
<option value=""></option>
<option value="1">Emergency Medical Responder (EMR)</option>
<option value="2">Emergency Medical Technician (EMT)</option>
<option value="3">Advanced EMT (AEMT)</option>
<option value="4">Paramedic</option>
</select></span>
<div id="intake_licensure_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_ems_funding-tr" sq_id="intake_ems_funding" req="1" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_ems_funding" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Which of the following best describes the primary source for how your EMS agency is funded?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><span><select role="listbox" aria-required="true" aria-labelledby="label-intake_ems_funding" class="x-form-text x-form-field " name="intake_ems_funding" tabindex="0">
<option value=""></option>
<option value="1">Municipal county</option>
<option value="2">Municipal city</option>
<option value="3">Franchise for profit</option>
<option value="4">Franchise non-profit</option>
<option value="5">Donations and grants</option>
</select></span>
<div id="intake_ems_funding_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_ems_responsemodel-tr" sq_id="intake_ems_responsemodel" req="1" style="display: none;">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_ems_responsemodel" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Which of the following describes your response model/service?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5">
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-intake_ems_responsemodel note-intake_ems_responsemodel label-intake_ems_responsemodel-1" tabindex="0" id="id-__chk__intake_ems_responsemodel_RC_1"
name="__chkn__intake_ems_responsemodel" code="1" onclick="checkboxClick('intake_ems_responsemodel','1',this,event,0);"><input type="hidden" value="" name="__chk__intake_ems_responsemodel_RC_1"> <label
id="label-intake_ems_responsemodel-1" class="mc" for="id-__chk__intake_ems_responsemodel_RC_1">Fire-based</label></div>
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-intake_ems_responsemodel note-intake_ems_responsemodel label-intake_ems_responsemodel-2" tabindex="0" id="id-__chk__intake_ems_responsemodel_RC_2"
name="__chkn__intake_ems_responsemodel" code="2" onclick="checkboxClick('intake_ems_responsemodel','2',this,event,0);"><input type="hidden" value="" name="__chk__intake_ems_responsemodel_RC_2"> <label
id="label-intake_ems_responsemodel-2" class="mc" for="id-__chk__intake_ems_responsemodel_RC_2">Hospital-based</label></div>
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-intake_ems_responsemodel note-intake_ems_responsemodel label-intake_ems_responsemodel-3" tabindex="0" id="id-__chk__intake_ems_responsemodel_RC_3"
name="__chkn__intake_ems_responsemodel" code="3" onclick="checkboxClick('intake_ems_responsemodel','3',this,event,0);"><input type="hidden" value="" name="__chk__intake_ems_responsemodel_RC_3"> <label
id="label-intake_ems_responsemodel-3" class="mc" for="id-__chk__intake_ems_responsemodel_RC_3">Private</label></div>
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-intake_ems_responsemodel note-intake_ems_responsemodel label-intake_ems_responsemodel-4" tabindex="0" id="id-__chk__intake_ems_responsemodel_RC_4"
name="__chkn__intake_ems_responsemodel" code="4" onclick="checkboxClick('intake_ems_responsemodel','4',this,event,0);"><input type="hidden" value="" name="__chk__intake_ems_responsemodel_RC_4"> <label
id="label-intake_ems_responsemodel-4" class="mc" for="id-__chk__intake_ems_responsemodel_RC_4">Third service</label></div>
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-intake_ems_responsemodel note-intake_ems_responsemodel label-intake_ems_responsemodel-5" tabindex="0" id="id-__chk__intake_ems_responsemodel_RC_5"
name="__chkn__intake_ems_responsemodel" code="5" onclick="checkboxClick('intake_ems_responsemodel','5',this,event,0);"><input type="hidden" value="" name="__chk__intake_ems_responsemodel_RC_5"> <label
id="label-intake_ems_responsemodel-5" class="mc" for="id-__chk__intake_ems_responsemodel_RC_5">Public utility</label></div>
<div class="choicevert" onclick=""><input type="checkbox" aria-labelledby="label-intake_ems_responsemodel note-intake_ems_responsemodel label-intake_ems_responsemodel-6" tabindex="0" id="id-__chk__intake_ems_responsemodel_RC_6"
name="__chkn__intake_ems_responsemodel" code="6" onclick="checkboxClick('intake_ems_responsemodel','6',this,event,0);"><input type="hidden" value="" name="__chk__intake_ems_responsemodel_RC_6"> <label
id="label-intake_ems_responsemodel-6" class="mc" for="id-__chk__intake_ems_responsemodel_RC_6">None of these apply</label></div>
<div class="space"></div>
<div id="intake_ems_responsemodel_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
<div id="note-intake_ems_responsemodel" class="note" aria-hidden="true">Select all that apply</div>
</td>
</tr>
<tr id="comments-tr" sq_id="comments">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-comments" aria-hidden="true">
<div class="rich-text-field-label">
<p><span style="font-weight: normal;">Additional comments / questions</span></p>
</div>
</label></td>
<td class="data col-5"> <textarea autocomplete="new-password" class="x-form-field notesbox" aria-labelledby="label-comments" id="comments" name="comments" tabindex="0"></textarea>
<div id="comments-expand" class="expandLinkParent d-print-none">
<a href="javascript:;" tabindex="-1" class="expandLink" onclick="growTextarea('comments')">Expand</a>
</div>
<div id="comments_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<tr id="intake_consent-tr" sq_id="intake_consent" req="1">
<td class="labelrc questionnum col-1" valign="top"></td>
<td class="labelrc col-6"><label class="fl" id="label-intake_consent" aria-hidden="true">
<div class="rich-text-field-label">
<p>Contact Information Sharing Consent</p>
<p><span style="font-weight: normal;">EMSC State Partnership Managers serve to support PECCs across the state/territory. C</span><span style="font-weight: normal;">an we provide your email address to you local EMSC State Partnership
Program?</span></p>
</div>
<div class="requiredlabel" aria-label="Question required.">* must provide value</div>
</label></td>
<td class="data col-5"><input name="intake_consent" value="" tabindex="-1" class="hiddenradio" aria-labelledby="label-intake_consent">
<div class="choicevert"><input type="radio" id="opt-intake_consent_1" tabindex="0" name="intake_consent___radio" aria-labelledby="label-intake_consent label-intake_consent-1"
onclick="document.forms['form'].intake_consent.value=this.value;" value="1"> <label id="label-intake_consent-1" for="opt-intake_consent_1" class="mc">Yes</label></div>
<div class="choicevert"><input type="radio" id="opt-intake_consent_0" tabindex="0" name="intake_consent___radio" aria-labelledby="label-intake_consent label-intake_consent-0"
onclick="document.forms['form'].intake_consent.value=this.value;" value="0"> <label id="label-intake_consent-0" for="opt-intake_consent_0" class="mc">No</label></div>
<div class="resetLinkParent d-print-none"><a href="javascript:;" class="smalllink " tabindex="0" style="display:;" onclick="radioResetVal('intake_consent','form');return false;">reset</a></div>
<div id="intake_consent_MDLabel" class="MDLabel" style="display:none" code="" label=""></div>
</td>
</tr>
<input type="hidden" name="submit-action" id="submit-action" value="Save Record">
<input type="hidden" name="record_id" id="record_id" value="712">
<input type="hidden" name="__page__" value="1">
<input type="hidden" name="__page_hash__" value="7f28501ca054bfce0398e4b1c59903dd">
<input type="hidden" name="__response_hash__"
value="baceea14d8373232219df94fd6873dc33300b37e463fc07b553828c41138a53bcaacf724264e51db0b752a69bb94be8c08b622151d99e15e77080eb763338323736b45a2035dae5e3840df16f663f3484481a6cfe5cef636c3267f3110e7a85483c1bd64f8b39aac9bcd98663b9b9bd1e6a4d08678436f7073008ecfab6c59a0">
<input type="hidden" name="intake_questionnaire_complete" value="">
<tr class="surveysubmit">
<td class="labelrc col-12" style="padding:5px;" colspan="3">
<table cellspacing="0">
<tbody>
<tr>
<td colspan="2" style="text-align:center;padding:15px 0;">
<button name="submit-btn-saverecord" tabindex="0" class="jqbutton nowrap ui-button ui-corner-all ui-widget" style="color:#800000;width:100%;max-width:140px;"
onclick="$(this).button("disable");dataEntrySubmit(this);return false;">Submit</button>
</td>
</tr>
<tr>
<td colspan="2" style="text-align:center;padding: 1px 0 10px;">
<button name="submit-btn-savereturnlater" tabindex="0" class="jqbutton ui-button ui-corner-all ui-widget" onclick="$(this).button("disable");dataEntrySubmit(this);return false;">Save & Return Later</button>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<input type="hidden" name="affiliation" value="">
</tbody>
</table>
</div>
</form>Name: form__1__the_pecc_arm_1 —
<form name="form__1__the_pecc_arm_1" enctype="multipart/form-data">
<input type="hidden" name="the_pediatric_emergency_care_coordinator_complete" value="">
</form>Name: form__2__patient_safety_arm_1 —
<form name="form__2__patient_safety_arm_1" enctype="multipart/form-data">
<input type="hidden" name="patient_safety_familycentered_care_complete" value="">
</form>Name: form__3__equip_suppl__me_arm_1 —
<form name="form__3__equip_suppl__me_arm_1" enctype="multipart/form-data">
<input type="hidden" name="equipment_supplies_and_medications_complete" value="">
</form>Name: form__4__policies__proce_arm_1 —
<form name="form__4__policies__proce_arm_1" enctype="multipart/form-data">
<input type="hidden" name="policies_procedures_complete" value="">
</form>Name: form__5__care_team_compe_arm_1 —
<form name="form__5__care_team_compe_arm_1" enctype="multipart/form-data">
<input type="hidden" name="care_team_competencies_complete" value="">
</form>Name: form__6__communication_arm_1 —
<form name="form__6__communication_arm_1" enctype="multipart/form-data">
<input type="hidden" name="communication_collaboration_across_systems_of_care_complete" value="">
</form>Name: form__7__qi_arm_1 —
<form name="form__7__qi_arm_1" enctype="multipart/form-data">
<input type="hidden" name="quality_improvement_complete" value="">
</form>Name: form__registration_arm_1 —
<form name="form__registration_arm_1" enctype="multipart/form-data">
<input type="hidden" name="affiliation" value="2">
</form>Text Content
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The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to
9-digit number, excluding leading zeros). Please try again.
The value you provided must be within the suggested range.
The value you provided is outside the suggested range.
This value is admissible, but you may wish to double check it.
The value entered must be a time value in the following format HH:MM within the
range 00:00-23:59 (e.g., 04:32 or 23:19).
This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it
now.
This field must be a 10 digit U.S. phone number (like 415 555 1212). Please
re-enter it now.
This field must be a valid email address (like joe@user.com). Please re-enter it
now.
The value you provided could not be validated because it does not follow the
expected format. Please try again.
Required format:
/^[uU][tT][sS][0][a-zA-Z0-9]{8}$/
/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/
/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/
/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/
/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/
/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))
(\d|[0-1]\d|[2][0-3]):[0-5]\d$/
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(\d|[0-1]\d|[2][0-3]):[0-5]\d$/
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(\d|[0-1]\d|[2][0-3]):[0-5]\d$/
/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))
(\d|[0-1]\d|[2][0-3])(:[0-5]\d){2}$/
/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))
(\d|[0-1]\d|[2][0-3])(:[0-5]\d){2}$/
/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))
(\d|[0-1]\d|[2][0-3])(:[0-5]\d){2}$/
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qqjKIsiQRQ37GAx9q82mfo4QN8mTZXnowZzJu4kah7QXaWmaapn9yFc7NeWfciXaaQ8TWJc5ez8DK87FQnAhfGKMur8xXp7f3uRJ5HeUwvrk
INTAKE QUESTIONNAIRE
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Welcome Sandra!
The following set of questions will help us get to know you a bit better. We
look forward to seeing you at our Kickoff Session on September 2nd at 1:30 ET /
12:30 CT.
Please note, your answers are completely confidential and this link is specific
to you. Please do not share this link with anyone else. If a colleague or
someone you know did not receive their intake questionnaire link, please have
them email me at pwdc@emscimprovement.center.
If you cannot finish this questionnaire in one sitting, you will be able to
resume your progress from any page by clicking on the "Save and Return Later"
button. This will take you to a page where you will receive a return code. You
will also be prompted to provide your email address and a link for the
questionnaire will be sent to your email. When you are ready to resume the
questionnaire, click on the web address from the email message, enter the return
code, and you will be directed back to your questionnaire.
Thank you!
Meredith
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removed!
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We would like to begin by learning a bit more about you.
Do you consider yourself a pediatric champion or a Pediatric Emergency Care
Coordinator (PECC)?
* must provide value
Yes
No
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We are currently conducting a survey to characterize the pediatric champion or
PECC position across the nation. Would you be willing to comple an additional
survey to help better define the pediatric champion/PECC role in the future and
assist with creating standards?
This should take approximately 15 minutes to complete.
* must provide value
Yes
No
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How many years have you been providing care for patients in an emergency
setting?
* must provide value
< 1 year1-5 years5-10 years10-1515-20 years> 20 yearsI do not provide direct
clinical care
How many years have you been working at your current organization?
* must provide value
< 1 year1-5 years5-10 years10-1515-20 years> 20 years
Do you have any specialized training in pediatric care?
* must provide value
Yes
No
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Please describe your pediatric training.
Expand
Are you planning to apply for continuing education or maintenance of
certification credit as part of your participation in this collaborative?
* must provide value
Yes
No
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How familiar are you with the concept of pediatric readiness and/or the National
Pediatric Readiness Project?
* must provide value
Not at all familiarSomewhat familiarFamiliarVery familiarExtremely familiar
Visit https://emscimprovement.center/domains/pediatric-readiness/ to learn more.
Please select the best descriptor of your knowledge of quality improvement (QI)
methodology.
* must provide value
I am completely new to QII have heard some of the QI concepts (drivers, change
strategies, etc) but have never used itI have a very basic working knowledge of
QII regularly use QI methods in my daily workI would consider myself an expert
in QI (e.g., hold certifications such as CPHQ, CPPS)
Which of the following is of highest priority for your EMSC program regarding
PECCs?
* must provide value
Develop a marketing strategy to promote PECCsDevelop a network of PECCsDevelop
education program for PECCsDevelop a PECC certification programDeveloping a PECC
requirement in Pediatric Recognition Programs (ED and EMS)Other
You selected "other" above. Please describe your EMSC program's highest priority
for PECCs.
* must provide value
Expand
What do you hope to take away from this collaborative?
* must provide value
Expand
Is there anything else that you would like us to know about you?
Expand
This section will inform us of you organizational structure.
Please select your ED from the following list.
* must provide value
Banner Ironwood Medical CenterOther, please specify below.
Please select you EMS agency.
* must provide value
Other, please specify below.
If you cannot find your organizaiton above, please enter it here.
What is the annual total (adult and pediatric) patient volume of your ED?
* must provide value
Low: < 10,000 patients per yearMedium: 10,000-49,999 patients per yearMedium to
High: 50,000-74,999 patients per yearHigh: >= 75,000 patients per year
Approximately how many total calls (both adult and pediatric) does your
organization respond to annually?
* must provide value
Numeric data only, e.g., 5000, not "five thousand"
What is the annual pediatric patient volume in your ED?
* must provide value
Low: < 1800 pediatric patients (average of 5 or fewer a day)Medium: 1,800-4,999
pediatric patients (average of 6-13 a day)Medium to High: 5,000-9,999 pediatric
patients (average of 14-26 a day)High: >= 10,000 pediatric patients (average of
27 or more a day)
Pediatric as defined by your organization. If no definition exists, use 0-18
years
What is the annual number of pediatric calls your organization respond to?
* must provide value
Low: < 12 pediatric calls in the last year (1 or fewer per month)Medium 13-100
pediatric calls in the last year (1-8 pediatric calls per month)Medium to High:
101-600 pediatric calls in the last year (8-50 pediatric calls per month)High:
>= 600 pediatric calls in the last year (more than 50 pediatric calls per month)
Pediatric as defined by your organization. If no definition exists, use 0-18
years
Please select the descriptor that best applies to your service area:
* must provide value
Remote / Tribal
Rural
Suburban
Urban
None of these apply
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Which of the following best describes your organization?
* must provide value
Critical Access
County
Community
Academic Medical Center
Children's Hospital
None of these apply
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Does your organization participate in a pediatric medical recognition program?
* must provide value
Yes
No
reset
Does your state have an established pediatric medical recognition program for
either EMS agencies or hospitals?
* must provide value
Yes
No
reset
Is your organization part of a hospital network or system?
* must provide value
Yes
No
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Name of Network
Which one of the following is the best description of your ED configuration for
the care of pediatric patients?
* must provide value
Pediatric ED in a Children's Hospital (hospital cares ONLY for children)
Separate pediatric ED in a general hospital (adult and children within one
hospital)
General ED (pediatric and adult patients seen in the same area)
Stand-by ED (physician on call)
Free-standing ED (ED unattached to a hospital with inpatient services)
Other
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pediatric as defined by your hospital
You marked "other" to the previous question.
Please describe your ED configuration for the care of children
* must provide value
Please select all designations that apply to your hospital :
* must provide value
STEMI/ACS
Stroke Center
American College of Surgeons Committee on Trauma (ACS-COT) verified Trauma
Center
State verified Trauma Center
Other
None
Trauma Center - ACS-COT Designated Level
Level 1Level 2Level 3Pediatric Level 1Pediatric Level 2
Trauma Center - State Designated Level
12345
You marked "other" to the previous question.
Please describe the other designation that applies to your hospital.
* must provide value
Has your emergency department completed the 2021 National Pediatric Readiness
Assessment?
* must provide value
Yes
No
reset
Visit https://www.pedsready.org for more information on the National Pediatric
Readiness Assessment.
Please enter you most recent pediatric readiness score, if available
Your nurse manager should have this information
What is the highest level of certification of your EMS agency?
* must provide value
Basic Life Support (BLS)Intermediate Life Support (ILS)Advanced Life Support
(ALS)
What is the highest level of licensure that pertains to the scope of care that
EMS providers in your agency provide to patients?
* must provide value
Emergency Medical Responder (EMR)Emergency Medical Technician (EMT)Advanced EMT
(AEMT)Paramedic
Which of the following best describes the primary source for how your EMS agency
is funded?
* must provide value
Municipal countyMunicipal cityFranchise for profitFranchise non-profitDonations
and grants
Which of the following describes your response model/service?
* must provide value
Fire-based
Hospital-based
Private
Third service
Public utility
None of these apply
Select all that apply
Additional comments / questions
Expand
Contact Information Sharing Consent
EMSC State Partnership Managers serve to support PECCs across the
state/territory. Can we provide your email address to you local EMSC State
Partnership Program?
* must provide value
Yes
No
reset
Submit Save & Return Later
YOU HAVE SELECTED AN OPTION THAT TRIGGERS THIS SURVEY TO END RIGHT NOW.
To save your responses and end the survey, click the 'End Survey' button below.
If you have selected the wrong option by accident and/or wish to return to the
survey, click the 'Return and Edit Response' button.
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