Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Designation *Practicing PhysicianResident PhysicianRN/RPNPARTOtherPlease SpecifyWhich of the following make up your current/future practice. (Select all that apply) *Office Family MedicineHospital Inpatient CareEmergency MedicineAnesthesiaObstetricsNeonatal ResuscitationHow would you rate your comfort with the following non-technical Crisis Resource Management Skills * Very UncomfortableSomewhat UncomfortableNeutralSomewhat ComfortableVery Comfortable Act as an effective leader in crisisAct as an effective leader in crisis Very UncomfortableAct as an effective leader in crisis Somewhat UncomfortableAct as an effective leader in crisis NeutralAct as an effective leader in crisis Somewhat ComfortableAct as an effective leader in crisis Very ComfortableAct as an effective helper in crisisAct as an effective helper in crisis Very UncomfortableAct as an effective helper in crisis Somewhat UncomfortableAct as an effective helper in crisis NeutralAct as an effective helper in crisis Somewhat ComfortableAct as an effective helper in crisis Very ComfortableMaintain effective situational awareness in crisisMaintain effective situational awareness in crisis Very UncomfortableMaintain effective situational awareness in crisis Somewhat UncomfortableMaintain effective situational awareness in crisis NeutralMaintain effective situational awareness in crisis Somewhat ComfortableMaintain effective situational awareness in crisis Very ComfortableMake effective decisions in crisisMake effective decisions in crisis Very UncomfortableMake effective decisions in crisis Somewhat UncomfortableMake effective decisions in crisis NeutralMake effective decisions in crisis Somewhat ComfortableMake effective decisions in crisis Very ComfortableCommunicate effectively in crisisCommunicate effectively in crisis Very UncomfortableCommunicate effectively in crisis Somewhat UncomfortableCommunicate effectively in crisis NeutralCommunicate effectively in crisis Somewhat ComfortableCommunicate effectively in crisis Very ComfortableManage your stress in crisisManage your stress in crisis Very UncomfortableManage your stress in crisis Somewhat UncomfortableManage your stress in crisis NeutralManage your stress in crisis Somewhat ComfortableManage your stress in crisis Very ComfortablePrioritize and manage tasks in crisisPrioritize and manage tasks in crisis Very UncomfortablePrioritize and manage tasks in crisis Somewhat UncomfortablePrioritize and manage tasks in crisis NeutralPrioritize and manage tasks in crisis Somewhat ComfortablePrioritize and manage tasks in crisis Very Comfortable Please indicate how helpful each of the following simulation themes would be for your practice * Not at all helpfulNot very helpfulNeutralHelpfulVery Helpful Medical EmergencyMedical Emergency Not at all helpfulMedical Emergency Not very helpfulMedical Emergency NeutralMedical Emergency HelpfulMedical Emergency Very HelpfulRespiratory EmergencyRespiratory Emergency Not at all helpfulRespiratory Emergency Not very helpfulRespiratory Emergency NeutralRespiratory Emergency HelpfulRespiratory Emergency Very HelpfulTrauma EmergencyTrauma Emergency Not at all helpfulTrauma Emergency Not very helpfulTrauma Emergency NeutralTrauma Emergency HelpfulTrauma Emergency Very HelpfulAirway EmergencyAirway Emergency Not at all helpfulAirway Emergency Not very helpfulAirway Emergency NeutralAirway Emergency HelpfulAirway Emergency Very HelpfulPediatric EmergencyPediatric Emergency Not at all helpfulPediatric Emergency Not very helpfulPediatric Emergency NeutralPediatric Emergency HelpfulPediatric Emergency Very HelpfulToxicologic EmergencyToxicologic Emergency Not at all helpfulToxicologic Emergency Not very helpfulToxicologic Emergency NeutralToxicologic Emergency HelpfulToxicologic Emergency Very HelpfulAnesthetic EmergencyAnesthetic Emergency Not at all helpfulAnesthetic Emergency Not very helpfulAnesthetic Emergency NeutralAnesthetic Emergency HelpfulAnesthetic Emergency Very HelpfulCardiac EmergencyCardiac Emergency Not at all helpfulCardiac Emergency Not very helpfulCardiac Emergency NeutralCardiac Emergency HelpfulCardiac Emergency Very HelpfulNeonatal EmergencyNeonatal Emergency Not at all helpfulNeonatal Emergency Not very helpfulNeonatal Emergency NeutralNeonatal Emergency HelpfulNeonatal Emergency Very Helpful Do you have any other signifiant educational goals that may be amenable to a simulation experience?Are there any simulation cases that you have already done that you would not want to repeat?Are there an cases/scenarios that may trigger you in an unpleasant way and should therefore be avoided?Do you have any food allergies or dietary requirements?MessageSubmit