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1 Page 1 of5 kimb@eastregion~ms.org Sign Out Help My Surveys Address Book Resources Plans & Pricing + Create Survey 2012 East Region Prehospital Training Assessment Education Edit Edit Survey r----~~ i Design Survey i Collect Responses Analyze Results I Preview Survey '!Se~~ surv~~;; To change the look of your survey, select a theme below. Blue Ice, : I [create Custom T~:m-=j r , ;~~_Add Page! 1. Agency Information EMS Training Needs Assessment for September June 2013 Thank you for participating in the East Region Prehospital Training Needs Assessment. This survey will take about five minutes to complete. Your input is critical to improving prehospital EMS training across the East Region. If you have questions at any time please contact the East Region Office at Q 1 [Edit Qu~~;;;;;;TiJr:~~;';l rco~~jl?~~j *1. Agency Information Official Agency, , Name: Agency License # Agency Mailing CitylTown: State: ZIP: County Agency Agency Phone: - select state- _EditorFull.aspx?sm=d... 2/6/2012

2 Survey Monkey - Question Builder Page 2 of5 *2. EMSlTraining Contact Info EMSlTraining 1' , Officer's Name: CitylTown: State: - select state- ZIP: Phone Number (cell phone preferred): 2. Initial EMS Classes Please indicate your initial training needs by identifying the class and number of students below in order of priority. Q3 ~Edit QuestionT-ilr M~! copyjl Delete! *3. Prioritize your top 3 Initial EMS Class Needs Priority 1 Priority 3 Identify Initial Classes ~!. Approx. # of Students 3. OTEP (On-Going Training & Education Program) Classes The East Region EMS Council currently funds a portion of OTEP training for EMS agencies. _EditorFull.aspx?sm=d... 2/6/2012

3 Page 3 of5 Q4 ~---;;a;;;sti-;;;;-itll_movel~. 'Y!ioelete j *4. Enter Total Number of (EMS) Providers to be trained that are registered with your agency and listed as primary? For your agency I I only: *5. Please prioritize your OTEP needs below. Priority 1 Priority 3 Priority 4 Priority 5 Other (please specify) Class Names ; + Add Page i Showthispageonly \4. Prehospitallnstructor Training I Please identify all of the training classes your agency may need. *6. Prehospitallnstructor Classes Class Names # of Students Priority 1 ;. i _EditorFull.aspx?sm=d... 2/6/2012

4 Page 4 of5 5. Other EMS Education Please identify and prioritize your other training choices including number of students and level of the class. Question Explanation and Student Cost Information > (PHTLS) Prehospital Trauma Life Support (Approx. Cost $275/student includes books) > (BTLS) Basic Trauma Life Support (Approx. Cost $200/student) > BLS (PEPP) Pediatric Educatioon for Prehospital Providers (Cost is approx $150/student) > ALS (PEPP) Pediatric Education for Prehospital Providers) Cost is approx $200/student > Emergency Pediatric Care (Basic 8 hour class) Cost is approx $150/student *7. Please prioritize other EMS Training opportunities. Priority 1 Priority 2 Class #of Students Level 6. Thank you for your participation! Thank you taking the time to participate in this important survey. Your input is greatly appreciated and will be used to help us improve Prehospital Training in the East Region. The East Region only funds BLS OTEP. By pressing "DONE" below your survey will be automatically submitted. If you have changes afte submitting the survey, please call the East Region EMS Office at Rod Heimbigner,Chair East Region Training & Education Committee 2/6/2012

5 Page 5 of5 r ;! + Add Page I I Back to My Surveys I I Preview Survey I ~e~~ &;"rvey -:J _EditorFull.aspx?sm=d... 2/6/2012