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Last Name: *

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Age:

In what state/province do you primarily practice? (select one) Alabama Alaska Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Manitoba Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland and Labrador North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon *

Which of the following EMS Practice Sites recruited you? AZ-AT Still University AZ-University of Arizona CA-CCSF CA-Centennial college CA-CHLA USC CA-Univ San Francisco Canada-Montreal-Montreal Children's Hospital(MCH) Canada-Montreal-Sainte-Justine Hospital University Ctr University of Montreal Canada-York-Regional Municipality of York CHU Sainte-Justine CT-Branford Fire CT-CCMC DE-Nemours Hospital for Children Wilmington,DE KS-Children's Mercy MA-Brigham & Women's Boston MA-UMASS MI-Kalamazoo Valley Community college MN-Childrens Hospital Minnesota MN-Mayo Clinic NE-Lincoln Memorial University NH-NHPediatricEMS.org NY-NY Presbyterian NY-Mt. Sinai Health System OH-MetroHealth Medical Center OH-Nationwide Childrens OH-Ohio State Med Ctr PA-CHOP PA-Geisinger Clinic RI-Brown Univ TN West TN-Mid TX-Dallas EMSC TX-Dell Children's Hosp TX-East Texas Medical Center EMS (ETMC EMS) TX-Friendswood Vol FD EMS division TX-McLennan Community College, TX-PHI Air Medical Houston TX-Port Aransas, TX TX-San Jacinto College Washington DC-Childrens National Yale-New Haven Children's Hospital Other

Number of years of service: *

Highest level of training: (select one) First Responder EMT Student EMT Paramedic Student Paramedic Prehospital-Physician Assistant Prehospital-Nurse Practitioner Prehospital-RN Prehospital-Physician Prehospital-Resident Physician Prehospital-Other RN: Diploma/certificate RN: Bachelor's Degree RN: Master's Degree Other *

Have you ever participated in a disaster training program? Yes No

If yes, then what type? National Disaster Medical Service Local disaster course Disaster Medical Assistance Team Course Other

Have you ever delivered care in a disaster or mass casualty event? (select one) Yes No *

If yes, then what type? Bus crash/motor vehicle collision Mass shooting Hurricane Tornado Explosion Other