The following has all of the text for you to create your own survey using whatever survey tool you like.
Note that, if you create your own, you may have to modify the output to use the our other modules—to avoid that, use our Google Forms template.
Template text below:
[Insert Your Institution Name] Advanced Practice Provider/CRNA Skills Survey
The COVID-19 crisis poses a massive human resources challenge to hospital systems that will increase as this pandemic spreads.
This survey is designed to help your institution manage staffing needs based on advanced practice provider and nurse anesthetist skillsets in the event redeployment is needed.
Thank you for your continued work and your willingness to help in these challenging times.
Last Name
__________________________________________
First Name
__________________________________________
Role
◯ PA ◯ NP ◯ CRNA ◯ Other:__________________
Your Primary Clinical Department (select one)
- Ambulatory/Outpatient
- Anesthesiology
- Critical Care
- Dermatology
- Emergency Medicine
- Family Medicine
- General Surgery
- Internal Medicine
- Neurology
- Neurosurgery
- Obstetrics-Gynecology
- Ophthalmology
- Orthopaedic Surgery
- Otolaryngology
- Pathology
- Pediatrics
- Plastic Surgery
- Physical Medicine & Rehabilitation
- Psychiatry
- Radiation Oncology
- Radiology
- Urology
- Other… Please Specify ________________________________
For the following skill sets or work examples, please check the box indicating your level of comfort:
SKILLED: This is a part of your current job, and you are very comfortable performing these actions (e.g. CRNA = intubation, critical care APP = ICU management).
NEED TRAINING: You have done this type of work before, but you would need some training or supervision to feel comfortable; or, this is not something you do every day but that you are willing to perform if necessary.
NOT COMFORTABLE: These are skills or tasks that you are either entirely unfamiliar with (and do not think you could learn in a safe way within 1-2 weeks), or that you would NOT be willing to do for any reason.
| SKILL/WORK | SKILLED | NEED TRAINING | NOT COMFORTABLE |
| Care of non-critical care COVID medicine patients | ◯ | ◯ | ◯ |
| General inpatient adult care | ◯ | ◯ | ◯ |
| General inpatient pediatric care | ◯ | ◯ | ◯ |
| Non-critical emergency department care (adults) | ◯ | ◯ | ◯ |
| Non-critical emergency department care (pediatrics) | ◯ | ◯ | ◯ |
| Ambulatory care | ◯ | ◯ | ◯ |
| Critical care/Vent management | ◯ | ◯ | ◯ |
| Obstetric care | ◯ | ◯ | ◯ |
| Bedside procedures (central lines, arterial lines) | ◯ | ◯ | ◯ |
| Intubation | ◯ | ◯ | ◯ |
| Triage/Screening for COVID | ◯ | ◯ | ◯ |
| Palliative care | ◯ | ◯ | ◯ |
Would you be willing to redeploy to non-clinical responsibilities if needed; e.g. patient transportation, room turnover, supply distribution?
◯ Yes ◯ No