Staff Perceptions of the Professional Practice Environment 2006

Size: px
Start display at page:

Download "Staff Perceptions of the Professional Practice Environment 2006"

Transcription

1 Staff Perceptions of the Professional Practice Environment 2006 Values Philosophy Standards of Practice Collaborative Decisionmaking Professional Development Patient Care Delivery Models Privileges, Credentialing, Peer Review Research Descriptive Care Theory Models Massachusetts General Hospital Patient Care Services Nursing Department The General Hospital Corporation,

2 Introduction: This survey should take about 30 minutes to complete. All survey answers will be kept completely confidential. Your answers will never be linked to your name and will never be used in a way that could identify you. The survey does contain a randomly generated ID number. Since the survey will be delivered two ways (paper and online), the ID number will be used by the Institute for Health Policy to track completed surveys to avoid any duplication of mailings and to ensure that each clinician only completes the survey once. Also, the ID number will enable you to complete the online survey over multiple sessions, should you not want to complete it during one session. The ID number will not be shared with anyone in MGH Patient Care Services. Survey responses will never be linked to your name. Please do not write your name on the questionnaire or the return envelope. The initial data analysis will report responses from all services within Patient Care Services. Secondary analysis will focus on unit data and data groupings (e.g. surgical services or physical therapy). Content analysis will be completed on the open-ended question across all Patient Care Services to identify themes. If permission is given, written comments for individual services will be presented as part of data reporting to each service. We are electronically reading responses from the surveys. Please answer all questions by filling in the circle completely. See the example below for how the circle should be filled in. The survey should be filled out in blue or black ink. Please do not write in the margins or make any errant marks outside of the circles on the survey since this may affect the electronic reading of survey responses. There is space at the end of the survey for written comments. Yes No Thank you for your willingness to participate in this survey. If you have any questions about the survey, please don t hesitate to contact Eric Campbell, Ph.D. at the Institute for Health Policy at or via at ecampbell@partners.org. 2

3 A. CLINICAL PRACTICE: In this section, statements refer to factors related to practice on your primary unit. Think of your primary unit as the work area, department, or clinical area of the hospital where you spend most of your work time. Please fill in the ONE circle that best reflects your level of disagreement or agreement with the following statements about clinical practice on your primary unit. 1. Leadership is supportive of nursing. 2. Nursing controls its own practice on my unit. 3. I have freedom to make important patient care and work decisions. 4. There is a lot of teamwork between nurses and doctors. 5. On my unit, patient care assignments foster continuity of care. 6. I have adequate support services to allow me to spend time with my patients. 7. I have enough time and opportunity to discuss patient care problems with other nurses. 8. On my unit, there are enough nurses on staff to provide quality patient care. 9. The nurse manager on my unit is a good manager and leader. 10. We have enough staff to get the work done. 11. There are opportunities to work on a highly specialized patient care unit. 3

4 A. CLINICAL PRACTICE (continued): Statements refer to factors related to practice on your primary unit. Think of your primary unit as the work area, department, or clinical area of the hospital where you spend most of your work time. Please fill in the ONE circle that best reflects your level of disagreement or agreement with the following statements about clinical practice on your primary unit. 12. My nurse manager supports the nursing staff in decision-making, even if the conflict is with a doctor. 13. Physicians and nurses have good working relationships. 14. On my unit, I am asked to do things against my professional judgment. 15. Overall, how dissatisfied or satisfied are you with your CLINICAL PRACTICE on your primary unit? (Please fill in ONE circle only) O O Very Dissatisfied Moderately Dissatisfied A Little Dissatisfied A Little Satisfied Moderately Satisfied Very Satisfied B. GENERAL RELATIONSHIPS AND COMMUNICATION: In this section, statements refer to factors related to general relationships and communication on your primary unit. Think of your primary unit as the work area, department, or clinical area of the hospital where you spend most of your work time. Please fill in the ONE circle that best reflects your level of disagreement or agreement with the following statements about general relationships and communication on your primary unit. 16. Information on the status of patients is available when I need it. 17. I receive information quickly when a patient's status changes. 18. Information regarding patient care is relayed without major delays. 4

5 19. Overall, how dissatisfied or satisfied are you with GENERAL RELATIONSHIPS AND COMMUNICATION on your primary unit? (Please fill in ONE circle only) O O Very Dissatisfied Moderately Dissatisfied A Little Dissatisfied A Little Satisfied Moderately Satisfied Very Satisfied C. TEAMWORK AND LEADERSHIP: In this section, statements refer to factors related to teamwork and leadership on your primary unit and other hospital units. Think of your primary unit as the work area, department, or clinical area of the hospital where you spend most of your work time. Please fill in the ONE circle that best reflects your level of disagreement or agreement with the following statements about teamwork and leadership on your primary unit. 20. My unit has constructive work relationships with other hospital units. 21. My unit does not receive the cooperation it needs from other hospital units. 22. Other hospital units seem to have a low opinion of my primary unit. 23. Inadequate working relationships with other hospital units limit the effectiveness of work within my primary unit. 24. Overall, how dissatisfied or satisfied are you with TEAMWORK AND LEADERSHIP on your primary unit? (Please fill in ONE circle only) O O Very Dissatisfied Moderately Dissatisfied A Little Dissatisfied A Little Satisfied Moderately Satisfied Very Satisfied 5

6 D. DISAGREEMENT/CONFLICT: In this section, statements refer to what happens when there is a disagreement or conflict on your primary unit. Think of your primary unit as the work area, department, or clinical area of the hospital where you spend most of your work time. Please fill in the ONE circle that best reflects your level of disagreement or agreement with the following statements about disagreement or conflict on your primary unit. 25. When staff on my unit disagree, they ignore the issue, pretending it will "go away." 26. Most conflicts occur with members from my own discipline. 27. Staff on my unit withdraw from conflict. 28. On my unit, all points of view are carefully considered in arriving at the best solution for the problem. 29. All staff on my unit work hard to arrive at the best possible solution. 30. On my unit, staff involved in a disagreement or conflict do not settle the dispute until all are satisfied with the decision. 31. Most conflicts occur with members from other disciplines. 32. Everyone on my unit contributes from their experience and expertise to produce a high quality solution for a conflict. 33. On my unit, disagreements between staff are ignored or avoided. 34. Staff involved in a disagreement or conflict settle the dispute by consensus. 6

7 35. Overall, how dissatisfied or satisfied are you with the way DISAGREEMENTS OR CONFLICTS are addressed on your primary unit? (Please fill in ONE circle only) O O Very Dissatisfied Moderately Dissatisfied A Little Dissatisfied A Little Satisfied Moderately Satisfied Very Satisfied E. INTERNAL WORK MOTIVATION: In this section, statements refer to your feelings about work. Please fill in the ONE circle that best reflects your level of disagreement or agreement with the following statements about your work motivation on your primary unit. 36. My opinion of myself goes up when I work on my primary unit. 37. I feel bad and unhappy when I discover that I have performed less well than I should. 38. I feel a high degree of personal responsibility for the work I do. 39. I feel a great sense of personal satisfaction when I do my work well. 40. I have challenging work that motivates me to do the best I can. 41. Working on my primary unit gives me the opportunity to gain new knowledge and skills. 42. I am motivated to do well because I am empowered by my work environment. 43. Working in this environment increases my sense of professional growth. 7

8 44. Overall, how dissatisfied or satisfied are you with your WORK MOTIVATION on your primary unit? (Please fill in ONE circle only) O O Very Dissatisfied Moderately Dissatisfied A Little Dissatisfied A Little Satisfied Moderately Satisfied Very Satisfied F. CULTURAL SENSITIVITY: In this section, statements refer to cultural sensitivity on your primary unit. Think of your primary unit as the work area, department, or clinical area of the hospital where you spend most of your work time. Please fill in the ONE circle that best reflects your level of disagreement or agreement with the following statements about cultural sensitivity on your primary unit. 45. Staff on my unit have access to the necessary resources to provide culturally competent care. 46. Staff on my unit are sensitive to the diverse patient population for whom they care. 47. Staff respect the diversity of their unit's health care team. 48. Overall, how dissatisfied or satisfied are you with CULTURAL SENSITIVITY on your primary unit? (Please fill in ONE circle only) O O Very Dissatisfied Moderately Dissatisfied A Little Dissatisfied A Little Satisfied Moderately Satisfied Very Satisfied G. OVERALL SATISFACTION Please fill in the ONE circle that best reflects your level of dissatisfaction or satisfaction with the following statement about your primary unit. Very Dissatisfied Dissatisfied Satisfied Very Satisfied 49. Overall, how satisfied are you working on your primary unit? 8

9 H. DEMOGRAPHICS: Please tell us a little about yourself. Fill in the blanks or fill in the circle that corresponds with your response. 50. What is your age? 51. Please indicate your gender. O Female O Male 52. What is your current work status? (Fill in ONE circle only) O Full time O Part time O Per diem 53. What is the highest level of education you have received? O Diploma O Master s degree not in your profession O Associate degree O Doctoral degree in your profession O Bachelors degree in your profession O Doctoral degree not in your profession O Bachelors degree not in your profession O Other (Please Specify: ) O Master s degree in your profession 54. Please indicate the year this degree was received: 55. How many years have you worked in your current profession? (# of years) 56. Which of the following best describes your current work setting? (Fill in the circle for all that apply) O O O Inpatient Outpatient Other (Please specify: ) 57. How many years have you worked at MGH? (# of years) 9

10 58. Have you attended the 8-hour Culturally Competent Care program offered by the Center for Clinical and Professional Development? (Fill in ONE circle only) O O Yes No I. Common Patient Problems: Below is a list of common patient problems encountered during the nurse/patient interaction. For each problem, please select how frequently you are exposed to the problem on your primary unit and also how prepared you are to address the problem? PATIENT PROBLEMS How frequently do you see this problem on your primary unit? (Fill in ONE circle only) Never Sometimes Often All of the time Not prepared at all How prepared are you to address this problem? (Fill in ONE circle only) 59. Risk for infection O O 60. Management of infection O O 61. Anxiety O O 62. Skin breakdown O O 63. Incontinence O O 64. Self-care deficit (Unable to complete ADLs) Very well prepared O O 65. Sleep disturbance O O 66. Obesity O O 67. Malnutrition O O 68. Falls O O 69. Risk for injury O O 70. Immobility O O 10

11 How frequently do you see this problem on your primary unit? (Fill in ONE circle only) PATIENT PROBLEMS Never Sometimes Often All of the time Not prepared at all How prepared are you to address this problem? (Fill in ONE circle only) 71. Violence O O 72. Anger O O 73. Confusion O O 74. Ineffective pain management O O 75. Family conflict O O 76. Fear O O 77. End of life ethical dilemmas O O 78. Substance abuse O O Very well prepared 79. Non-invasive mechanical ventilation O O 80. Invasive mechanical ventilation O O 81. Wound O O 82. Ostomy O O 83. Airway management O O 84. Ineffective code status conflict O O 85. Risk for knowledge deficit O O 11

12 I. Other Common Patient Problems: If you encounter other common patient problems please list them below. For each problem, please select how frequently you are exposed to the problem on your primary unit and also how prepared you are to address the problem? PATIENT PROBLEMS Other (please specify below) How frequently do you see this problem on your primary unit? (Fill in ONE circle only) Never Sometimes Often All of the time Not prepared at all How prepared are you to address this problem? (Fill in ONE circle only) Very well prepared 86. O O 87. O O 88. O O 89. O O YOUR COMMENTS: Please feel free to write any comments you have in regards to any of the topics in this survey as well as topics not covered in this survey that pertain to the professional practice environment. I give permission for any comments above to be included in a list of general responses to be shared with my Associate Chief Nurse. (Please fill in ONE circle only) O Yes, release my comments O No, do not release my comments THANK YOU FOR YOUR TIME AND EFFORT IN COMPLETING THIS SURVEY. PLEASE RETURN THIS SURVEY IN THE ENCLOSED ENVELOPE BY September 25, Staff Perceptions of the Professional Practice Environment The Institute for Health Policy Massachusetts General Hospital 50 Staniford St., 9 th Floor Boston, MA The General Hospital Corporation,

Most of the questions on the following pages can be answered by simply checking the box below or alongside the answer that applies to you.

Most of the questions on the following pages can be answered by simply checking the box below or alongside the answer that applies to you. Agency Logo Serial Number: Respondent ID - - First Name/Initials Interview Date: Interviewer ID: "50+ in Europe" The Survey of Health, Ageing and Retirement in Europe 2010/11 Self-Administered Questionnaire

More information

Your Social Care and Support Services

Your Social Care and Support Services Your Social Care and Support Services Introduction We are contacting you because you receive, or have received, care and support services that are paid for (at least in part) by [your local Social Services

More information

Employee Engagement Survey Results. Sample Company. All Respondents

Employee Engagement Survey Results. Sample Company. All Respondents Employee Engagement Survey Results All Respondents Summary Results from 246 Respondents February, 2009 Table of Contents All Respondents (n = 246) 1 Employee Engagement Two-Factor Profile of Employee Engagement

More information

San Diego State University Consent to Act as a Research Subject

San Diego State University Consent to Act as a Research Subject San Diego State University Consent to Act as a Research Subject You are being asked to participate in a research study. Before you give your consent to be a part of the study, carefully read the following

More information

Physician Survey. Collaboration with the Nurse Practitioner in Long-Term Care

Physician Survey. Collaboration with the Nurse Practitioner in Long-Term Care Collaborative Practice by Nurse Practitioners and Physicians in Long-Term Care Facilities: A Mixed-Methods Study Faith C. Donald and Alba DiCenso McMaster University Physician Survey Collaboration with

More information

Survey of Nurses 2012

Survey of Nurses 2012 Survey of Nurses 2012 EXECUTIVE SUMMARY In 2012, the Michigan Center for Nursing conducted the ninth annual survey of nurses licensed in Michigan. The samples for this survey and previous surveys were

More information

Survey of Nurses 2013

Survey of Nurses 2013 Survey of Nurses 2013 Survey of Nurses Report Summary Since 2004, the Michigan Center for Nursing has conducted an annual survey of Michigan nurses in conjunction with the licensure renewal process for

More information

Minnesota Registered Nurse Workforce Survey

Minnesota Registered Nurse Workforce Survey Minnesota Registered Nurse Workforce Survey Survey Instructions Using a pen or pencil, please clearly indicate your response to each question by completely filling in the appropriate square (example: )

More information

Licensed Independent Clinical Social Workers Renewal/Reinstatement Application

Licensed Independent Clinical Social Workers Renewal/Reinstatement Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Clinical Social Workers 802-828-1505 renewalclerk@sec.state.vt.us www.vtprofessionals.org

More information

Contents of This Packet

Contents of This Packet Contents of This Packet 1) Overview letter 2) Dialectical Behavior Therapy (DBT) Clinic flyer 3) Diagnostic criteria for borderline personality disorder 4) Guidelines and agreements for participating in

More information

Health care decisions: Planning in advance

Health care decisions: Planning in advance 450 Brookline Ave. Boston, MA 02215 www.dana-farber.org MASSACHUSETTS HEALTH CARE PROXY Expressing your wishes regarding your care and treatment Health care decisions: Planning in advance You have the

More information

Examples of Teacher-Designed/Scored Feedback Questionnaires A Guided Self-Analysis for Beginning Instructors

Examples of Teacher-Designed/Scored Feedback Questionnaires A Guided Self-Analysis for Beginning Instructors Examples of Teacher-Designed/Scored Feedback Questionnaires A Guided Self-Analysis for Beginning Instructors Teaching is a complex process that rests in large part on the quality of the exchanges between

More information

Rural Health Information Technology Cooperative. Clinician Survey on Quality Improvement, Best Practice Guidelines, and Information Technology

Rural Health Information Technology Cooperative. Clinician Survey on Quality Improvement, Best Practice Guidelines, and Information Technology Rural Health Information Technology Cooperative Clinician Survey on Quality Improvement, Best Practice Guidelines, and Information Technology Conducted for: The Rural Healthcare Quality Network Conducted

More information

Counseling Intake Form (Each person attending therapy should complete a form)

Counseling Intake Form (Each person attending therapy should complete a form) Counseling Intake Form (Each person attending therapy should complete a form) Name Male Female Mailing Address Date of Birth Home Phone Work Email How would you like to be contacted? Home Work Email Okay

More information

Trends in Rehabilitation Services 2012

Trends in Rehabilitation Services 2012 Trends in Rehabilitation Services 2012 Introduction The purpose of this survey was to capture a baseline measurement of attitudes and workforce trends among physical therapists, occupational therapists

More information

REQUEST FOR INDEPENDENT EXTERNAL REVIEW OF A HEALTH INSURANCE GRIEVANCE THROUGH THE OFFICE OF PATIENT PROTECTION

REQUEST FOR INDEPENDENT EXTERNAL REVIEW OF A HEALTH INSURANCE GRIEVANCE THROUGH THE OFFICE OF PATIENT PROTECTION The Commonwealth of Massachusetts Health Policy Commission Office of Patient Protection 50 Milk Street, 8 th Floor Boston, MA 02109 (800)436-7757 (phone) (617)624-5046 (fax) REQUEST FOR INDEPENDENT EXTERNAL

More information

Program Assessment Report. Unit Psychology Program name: Clinical Psychology MA Completed by David Grilly May 2007

Program Assessment Report. Unit Psychology Program name: Clinical Psychology MA Completed by David Grilly May 2007 Program Assessment Report Unit Psychology Program name: Clinical Psychology MA Completed by David Grilly May 2007 This is a two year M.A. professional program in clinical psychology, which consists of

More information

External Review Request Form

External Review Request Form External Review Request Form This EXTERNAL REVIEW REQUEST FORM must be filed with the Nebraska Department of Insurance within FOUR (4) MONTHS after receipt from your insurer of a denial of payment on a

More information

Survey of Advanced Practice Nurses 2010

Survey of Advanced Practice Nurses 2010 Survey of Advanced Practice s 2010 INTRODUCTION AND METHODOLOGY In 2010, the Michigan Center for Nursing and Office of the Chief Executive asked Public Sector Consultants Inc. to conduct a survey of advanced

More information

Michigan Department of Community Health

Michigan Department of Community Health Michigan Department of Community Health INTRODUCTION The Michigan Department of Community Health asked Public Sector Consultants Inc. (PSC) to conduct a survey of licensed pharmacists in 2005 to gather

More information

Advanced Practice Registered Nurse Renewal/Reinstatement Application Current Expiration 03/31/2015

Advanced Practice Registered Nurse Renewal/Reinstatement Application Current Expiration 03/31/2015 Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 056203402 Board of Nursing (802) 8285924 www.vtprofessionals.org Advanced Practice

More information

MASSACHUSETTS GENERAL HOSPITAL Department of Nursing

MASSACHUSETTS GENERAL HOSPITAL Department of Nursing Page 1 of 21 MASSACHUSETTS GENERAL HOSPITAL Department of Nursing TITLE: CREDENTIALING AND AUTHORIZATION OF NURSES IN THE EXPANDED ROLES AND PHYSICIAN ASSISTANTS WHO ARE MGH AND MGPO EMPLOYEES POLICY:

More information

Arrive 15 minutes before your scheduled appointment time.

Arrive 15 minutes before your scheduled appointment time. Thank you for choosing Dr. Townsend and Associates, P.A. for your counseling and evaluation needs. We respect your time and would like to provide you with a full 45 minute session. In order for your therapist

More information

MISCONDUCT INCIDENT REPORT

MISCONDUCT INCIDENT REPORT DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Quality Assurance DHS 13.05(3)(a), Wis. Admin. Code F-62447 (Rev. 04/10) Page 1 of 8 MISCONDUCT INCIDENT REPORT GENERAL INSTRUCTIONS Use this

More information

Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC

Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC Great Bay Mental Health Associates, Inc. Notice to Clients and Consent to Mental Health Treatment Agreement Courtney A. Atherton, MA, LCMHC, MLADC Patient Name (please print): Welcome to the therapy services

More information

Please answer each question by filling in the blank or by marking the box to the left of your answer.

Please answer each question by filling in the blank or by marking the box to the left of your answer. SAFE SURGERY 5: SOUTH CAROLINA Tool 1: Checklist Implementation Leader Survey This questionnaire requests information about the hospital in which you work, the surgical service or services in which the

More information

Alumni, Employer, and Site Supervisor (AESS) Surveys School Counseling & Clinical Mental Health Counseling Programs Annual Report Summary, 2011

Alumni, Employer, and Site Supervisor (AESS) Surveys School Counseling & Clinical Mental Health Counseling Programs Annual Report Summary, 2011 School of Education Department of Human Services & Counseling Counselor Education Programs Alumni, Employer, and Site Supervisor (AESS) Surveys School Counseling & Clinical Mental Health Counseling Programs

More information

Survey of Team Attitudes and Relationships (STAR)

Survey of Team Attitudes and Relationships (STAR) F 0 6 Survey of Team Attitudes and Relationships (STAR) The purpose of this survey is to find out how you feel about your work in hospice. Please read each item carefully, then select the response that

More information

North Bay Regional Health Centre

North Bay Regional Health Centre Addictions and Mental Health Division Programs Central Intake Referral Form The Central Intake Referral Form is used in the District of Nipissing by the North Bay Regional Health Centre s Addictions and

More information

Client Intake Information. Client Name: Home Phone: OK to leave message? Yes No. Office Phone: OK to leave message? Yes No

Client Intake Information. Client Name: Home Phone: OK to leave message? Yes No. Office Phone: OK to leave message? Yes No : Chris Groff, JD, MA, Licensed Pastor Certified Sex Addiction Therapist Candidate 550 Bailey, Suite 235 Fort Worth, Texas 76107 Client Intake Information Client Name: Street Address: City: State: ZIP:

More information

Patient Rights, Responsibilities and Durable Power of Attorney

Patient Rights, Responsibilities and Durable Power of Attorney Patient Rights, Responsibilities and Durable Power of Attorney www.sparrow.org Table of Contents Patient Rights...4 Information Upon Delivery of Care...4 Quality of Care...5 Pain Relief...5 Response to

More information

Jane Beresford, Psy.D. Licensed Psychologist PSY 16618 (310) 551-8535 Info@DrBeresford.com 15300 Ventura Boulevard, Suite 301

Jane Beresford, Psy.D. Licensed Psychologist PSY 16618 (310) 551-8535 Info@DrBeresford.com 15300 Ventura Boulevard, Suite 301 Patient Information (PLEASE PRINT) Patient Name: _ Today s Date: Patient s SSN: - - DOB: / / Age: Sex: Marital Status (circle): Single Married Separated Divorced Other: Home Address: Email: OK to leave

More information

CERTIFIED REGISTERED NURSE ANESTHETISTS IN VERMONT 2013 RE-LICENSURE SURVEY

CERTIFIED REGISTERED NURSE ANESTHETISTS IN VERMONT 2013 RE-LICENSURE SURVEY CERTIFIED REGISTERED NURSE ANESTHETISTS IN VERMONT 2013 RE-LICENSURE SURVEY Prepared by: Mary Val Palumbo DNP, APRN AHEC NURSING WORKFORCE, RESEARCH, PLANNING and DEVELOPMENT University of Vermont 1 PURPOSE

More information

Glen Davis PhD Maine Child Psychology 2 Elm Street, Waterville, ME 04901 Telephone: (207) 221-2631 Fax: (207) 221-3368 MaineChildPsych.

Glen Davis PhD Maine Child Psychology 2 Elm Street, Waterville, ME 04901 Telephone: (207) 221-2631 Fax: (207) 221-3368 MaineChildPsych. Dear Parent, Glen Davis PhD Maine Child Psychology 2 Elm Street, Waterville, ME 04901 Telephone: (207) 221-2631 Fax: (207) 221-3368 MaineChildPsych.com Thank you for your interest in psychological services

More information

The Clarity Psychological Group 3915 Cascade Rd. SW Suite 250 Atlanta, GA 30331 P. (404) 699-3170 F. (404) 699-5680

The Clarity Psychological Group 3915 Cascade Rd. SW Suite 250 Atlanta, GA 30331 P. (404) 699-3170 F. (404) 699-5680 The Clarity Psychological Group 3915 Cascade Rd. SW Suite 250 Atlanta, GA 30331 P. (404) 699-3170 F. (404) 699-5680 Dear Client: It is a pleasure to have you in our practice. We appreciate the opportunity

More information

Client Information Sheet

Client Information Sheet BOB JASKIEWICZ, L.C.S.W. Psychotherapist MONTCLAIR HEALTH ASSOCIATES Client Information Sheet Name _ Age Gender M F Marital Status Name(s) and DOB for all other family members Home address (city, state,

More information

Client Satisfaction Quality Improvement Tool and Sample Surveys

Client Satisfaction Quality Improvement Tool and Sample Surveys Client Satisfaction Quality Improvement Tool and Sample Surveys August 2011 Prepared For California Department of Public Health, Office of Family Planning Family PACT Technical Assistance and Training

More information

Networked Personal Health Records

Networked Personal Health Records Networked Personal Health Records Table of Contents Potential of Personal Health Records (PHRs) What is a PHR? Common functions of a PHR Ideal attributes The PHR environment Consumer perceptions about

More information

Workers' Compensation History

Workers' Compensation History Workers' Compensation History 3025 N. Taft Avenue, Suite A Loveland, Colorado 80538 Phone: 970.203.0621 Fax: 970.461.2462 Name: Age: Date: Sex: M / F Address: City: State: Zip: Social Security Number:

More information

Idaho Peer Support Specialist Training Application

Idaho Peer Support Specialist Training Application Idaho Peer Support Specialist Training Application This application must be received no later than July 31, 2015 Before completing this application, please first review the minimum requirements for applicants

More information

You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed)

You are scheduled to see Dr. Kennard: at. On the day of your visit, he will be located at: (Directions are enclosed) Your dermatologist has referred you for treatment of your skin condition. We would like to take this opportunity to welcome you and give you information that will make your appointment with us go smoothly.

More information

GQ Medical School Graduation Questionnaire. All Schools Summary Report FINAL

GQ Medical School Graduation Questionnaire. All Schools Summary Report FINAL 2010 GQ Medical School Graduation Questionnaire All Schools Summary Report FINAL Prepared by Academic Affairs 202-828-0960 email: gq@aamc.org 2010, Association of American Medical Colleges. All rights

More information

LESSON FIVE. The Nursing Process and Critical Thinking

LESSON FIVE. The Nursing Process and Critical Thinking Introduction LESSON FIVE The Nursing Process and Critical Thinking Registered Nurses must use organized, critical thought to make judgements, solve problems and care for clients. We no longer blindly follow

More information

Capstone Suggestions for Survey Development for Research Purposes

Capstone Suggestions for Survey Development for Research Purposes Capstone Suggestions for Survey Development for Research Purposes 1. Begin by listing the questions you would like to answer with the survey. These questions will be relatively broad and should be based

More information

Employee Health Care Decisions Survey 2006

Employee Health Care Decisions Survey 2006 Employee Health Care Decisions Survey 2006 1. Have you ever heard of the term, Health Care Proxy? yes no (skip to Q6) 2. From what you have heard, which of the following best describes a Health Care Proxy?

More information

James A. Purvis, Ph.D. Psychotherapy Services Agreement

James A. Purvis, Ph.D. Psychotherapy Services Agreement James A. Purvis, Ph.D. Psychotherapy Services Agreement PSYCHOLOGICAL SERVICES Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist

More information

Professional Development Landscape of Early Childhood Education in Detroit

Professional Development Landscape of Early Childhood Education in Detroit Professional Development Landscape of Early Childhood Education in Detroit Description of Respondents In fall 2014, ESD fielded a survey on professional development status, aspirations, and barriers to

More information

Grapevine Behavioral Healthcare Associates 2311 Mustang Dr #300, Grapevine, TX 76051 Office (817) 481-7474 Fax (817) 416-0900

Grapevine Behavioral Healthcare Associates 2311 Mustang Dr #300, Grapevine, TX 76051 Office (817) 481-7474 Fax (817) 416-0900 PATIENT INFORMATION Parent/Guardian Name (if patient is child/adolescent): Last Name: First Name: Middle: Social Security #: of Birth: Gender (please circle): Male Female Street Address: City, State, Zip

More information

Survey of Registered Nurses 2008

Survey of Registered Nurses 2008 California Board of Registered Nursing Survey of Registered Nurses 2008 Conducted for the Board of Registered Nursing by School of Nursing, University of California, San Francisco and Center for the Health

More information

Garland s Christian Counseling Center

Garland s Christian Counseling Center Garland s Christian Counseling Center : PERSONAL DATA Name: Email: Home Phone: Address: Cell Phone: Work Phone: (Street, City, Zip Code) DL #, ST & Exp : SS#: DOB: Sex: Please circle where we may leave

More information

Intake Form. Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #:

Intake Form. Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #: Intake Form PATIENT INFORMATION Patient Last Name: First Name: Marital Status: Date of Birth: Street Address: City: State: Zip: Home Phone: Cell Phone: Work Phone: Social Security #: Gender: Employer:

More information

NURSE LIFE CARE PLANNING CONSENSUS STATEMENT CODE OF PROFESSIONAL ETHICS AND CONDUCT

NURSE LIFE CARE PLANNING CONSENSUS STATEMENT CODE OF PROFESSIONAL ETHICS AND CONDUCT 1 NURSE LIFE CARE PLANNING CONSENSUS STATEMENT CODE OF PROFESSIONAL ETHICS AND CONDUCT Preface The Code of Professional Ethics and Conduct for the American Association of Nurse Life Care Planners is based

More information

MAINE K-12 & SCHOOL CHOICE SURVEY What Do Voters Say About K-12 Education?

MAINE K-12 & SCHOOL CHOICE SURVEY What Do Voters Say About K-12 Education? MAINE K-12 & SCHOOL CHOICE SURVEY What Do Voters Say About K-12 Education? Interview Dates: January 30 to February 6, 2013 Sample Frame: Registered Voters Sample Sizes: MAINE = 604 Split Sample Sizes:

More information

Registered Nurse Renewal/Reinstatement Application

Registered Nurse Renewal/Reinstatement Application Vermont Secretary of State Attn: Renewal Clerk Office of Professional Regulation 89 Main St. 3 rd Floor Montpelier, VT 05620-3402 Board of Nursing Renewal Clerk (802) 828-2396 www.vtprofessionals.org Current

More information

Welcome to Tri-State Rehab Services

Welcome to Tri-State Rehab Services Welcome to Tri-State Rehab Services Ashland Ironton Jackson Louisa New Boston Westmoreland Thank you for choosing our facility. To help us meet all your physical therapy needs, please fill out forms completely

More information

Acute Care Pediatric Nurse Practitioner Certification Exam. Detailed Content Outline

Acute Care Pediatric Nurse Practitioner Certification Exam. Detailed Content Outline Acute Care Pediatric Nurse Practitioner Certification Exam Description of the Specialty This exam is for the pediatric nurse practitioner (PNP) who has graduated from a formal acute care PNP program with

More information

CERTIFIED NURSE MIDWIVES IN VERMONT 2013 RE-LICENSURE SURVEY

CERTIFIED NURSE MIDWIVES IN VERMONT 2013 RE-LICENSURE SURVEY CERTIFIED NURSE MIDWIVES IN VERMONT 2013 RE-LICENSURE SURVEY Prepared by: Mary Val Palumbo DNP, APRN AHEC NURSING WORKFORCE, RESEARCH, PLANNING and DEVELOPMENT University of Vermont 1 PURPOSE The UVM Area

More information

Your Rights To Make Health Care Decisions. A Summary of Connecticut Law

Your Rights To Make Health Care Decisions. A Summary of Connecticut Law Your Rights To Make Health Care Decisions A Summary of Connecticut Law prepared by the Office of the Attorney General for the Department of Social Services and Department of Public Health 2011 Your Rights

More information

PCP: Page 1 of 5. SECTION: Personnel. POLICY AND PROCEDURE: Personnel Training: Elder Abuse Reporting

PCP: Page 1 of 5. SECTION: Personnel. POLICY AND PROCEDURE: Personnel Training: Elder Abuse Reporting PCP: Page 1 of 5 SECTION: Personnel POLICY AND PROCEDURE: Personnel Training: Elder Abuse Reporting Approved date: Approved by: Effective date: Revised date: Revised date: POLICY: Any mandated reporter

More information

PROTECTIVE ORDER UNIT QUESTIONNAIRE FANNIN COUNTY CRIMINAL DISTRICT ATTORNEY S OFFICE

PROTECTIVE ORDER UNIT QUESTIONNAIRE FANNIN COUNTY CRIMINAL DISTRICT ATTORNEY S OFFICE PROTECTIVE ORDER UNIT QUESTIONNAIRE FANNIN COUNTY CRIMINAL DISTRICT ATTORNEY S OFFICE HOW TO USE THE QUESTIONNAIRE USE BLACK INK ONLY blue ink and other colors of ink are difficult to read, especially

More information

Z Take this folder with you to your

Z Take this folder with you to your my health care notebook Why? Being an active part of your health care team helps you feel better and helps you get even better care. Starting on Day 1, you can keep track of important information and questions.

More information

One. Choosing the Care You Want: ADVANCE DIRECTIVES

One. Choosing the Care You Want: ADVANCE DIRECTIVES One Choosing the Care You Want: ADVANCE DIRECTIVES At Carolinas HealthCare System, we believe your care should line up with your health goals at each stage of your life. In good health and in sickness,

More information

PSYCHOTHERAPY: HOW TO GET STARTED

PSYCHOTHERAPY: HOW TO GET STARTED PSYCHOTHERAPY: HOW TO GET STARTED I didn t want to talk about my problems with someone I didn t know. Then I learned how common it is to initially feel hesitant and to even try several therapists before

More information

After each scenario and each principle, participants in the reflection condition also see the following prompt:

After each scenario and each principle, participants in the reflection condition also see the following prompt: Supplementary Online Material for Eric Schwitzgebel and Fiery Cushman Professional Philosophers Susceptibility to Order Effects and Framing Effects in Evaluating Moral Dilemmas Initial Instructions: Non-Reflection

More information

Miramar College Transfer Center Point-of-Service Survey Executive Summary Spring 2009

Miramar College Transfer Center Point-of-Service Survey Executive Summary Spring 2009 Miramar College Transfer Center Point-of-Service Survey Executive Summary Spring 2009 Prepared by: May 2009 Table of Contents Overview and Purpose... 3 Methodology... 3 Instrumentation... 3 Survey Population...

More information

i n s e r v i c e Resident Rights

i n s e r v i c e Resident Rights i n s e r v i c e Resident Rights The term resident rights refers to legislation that protects nursing home residents and provides for certain freedoms. Resident rights are extremely important and are

More information

Chronic Conditions/Diagnoses: Medications and Dosage: Take medications as prescribed? Yes

Chronic Conditions/Diagnoses: Medications and Dosage: Take medications as prescribed? Yes Referral Form for Supportive Services for Adults with Mental Illness Residential Services Care Coordination East Side Center Congregate Care Living - Group Homes Congregate Care Living - Maple Street and

More information

Dr. Joshua D. Dion DNP, A.C.N.P-BC, R.N.-BC. Northeastern University, Boston MA, Doctor of Nursing Practice Degree (January 2014).

Dr. Joshua D. Dion DNP, A.C.N.P-BC, R.N.-BC. Northeastern University, Boston MA, Doctor of Nursing Practice Degree (January 2014). Dr. Joshua D. Dion DNP, A.C.N.P-BC, R.N.-BC Education: Northeastern University, Boston MA, Doctor of Nursing Practice Degree (January 2014). MGH Institute of Health Professions, Boston, MA, Master of Science

More information

Exploring the Value of Continuing Education Mandates

Exploring the Value of Continuing Education Mandates VOLUME 6 SEPTEMBER 2003 NCSBN Research Brief Report of Findings Exploring the Value of Continuing Education Mandates June Smith, PhD, RN National Council of State Boards of Nursing, Inc. (NCSBN) i Report

More information

Psychiatric Residential Treatment Facility Referral

Psychiatric Residential Treatment Facility Referral Psychiatric Residential Treatment Facility Referral Date of referral: Psychiatric Residential Treatment Facility (PRTF) Referral Information Referral contact: Phone number: Referring facility/agency: Fax

More information

005. Independent Review Organization External Review Annual Report Form

005. Independent Review Organization External Review Annual Report Form Title 210 NEBRASKA DEPARTMENT OF INSURANCE Chapter 87 HEALTH CARRIER EXTERNAL REVIEW 001. Authority This regulation is adopted by the director pursuant to the authority in Neb. Rev. Stat. 44-1305 (1)(c),

More information

General Membership Handbook

General Membership Handbook General Membership Handbook Revised: December 22, 2010 Table of Contents 1. Membership as a Research Scientist A. Membership Requirements B. Eligibility C. Application Process D. Fees E. Renewal Process

More information

CHAPTER 7: RIGHTS AND RESPONSIBILITIES

CHAPTER 7: RIGHTS AND RESPONSIBILITIES We want to make sure you are aware of your rights and responsibilities, as well as those of your Tufts Health Together (MassHealth), Tufts Health Forward (Commonwealth Care), Tufts Health Extend, Network

More information

Advance Directives: Planning for Future Health Care Decisions

Advance Directives: Planning for Future Health Care Decisions CONNECTICUT Advance Directives: Planning for Future Health Care Decisions Your Rights to Make Health Care Decisions and Frequently Asked Questions A Summary of Connecticut Law Directions for Completing

More information

Medical Assistant-Phlebotomist Certification Application Packet

Medical Assistant-Phlebotomist Certification Application Packet Medical Assistant-Phlebotomist Certification Application Packet Contents: 1. 651-007...Contents List/SSN Information/Mailing Information...1 page 2. 651-008...Application Instructions Checklist... 2 pages

More information

Policy and Procedure for Handling and Learning from Feedback, Comments, Concerns and Complaints

Policy and Procedure for Handling and Learning from Feedback, Comments, Concerns and Complaints Policy and Procedure for Handling and Learning from Feedback, Comments, Concerns and Complaints Author: Shona Welton, Head of Patient Affairs Responsible Lead Executive Director: Endorsing Body: Governance

More information

2013 Health Careers Summer Camp Application Checklist

2013 Health Careers Summer Camp Application Checklist 2013 Health Careers Summer Camp Application Checklist Please use this checklist to confirm that all required documents have been obtained and completed before mailing your complete application packet to

More information

THE DESKTOP CONSULTANT TABLE OF CONTENTS

THE DESKTOP CONSULTANT TABLE OF CONTENTS THE DESKTOP CONSULTANT TABLE OF CONTENTS SECTION 1: INTRODUCTION to the Year 2011 Changes Authorizations and Restrictions for Use About Your Files Dedication Acknowledgements Preface Organization How to

More information

Health Information Technology and Workflow. Clinician and Office Staff Survey

Health Information Technology and Workflow. Clinician and Office Staff Survey Appendix M: Web-based Survey Form Approved OMB No. 0935-0212 Exp. Date 07/31/2016 Health Information Technology and Workflow Clinician and Office Staff Survey Public reporting burden for this collection

More information

Questionnaire for. Duke College Major and Expectations Survey (DuCMES) May 2009

Questionnaire for. Duke College Major and Expectations Survey (DuCMES) May 2009 Questionnaire for Duke College Major and Expectations Survey (DuCMES) May 2009 Peter Arcidiacono V. Joseph Hotz Songman Kang Department of Duke University CONSENT FORM FOR RESEARCH Thank you for considering

More information

Boston Area Health Education Center

Boston Area Health Education Center Boston Area Health Education Center Youth to Health Careers Program Application Checklist Due March 12th, 2014 Full Name: School: Best Phone to Contact You: Grade: The Youth to Health Careers (Y 2 HC)

More information

Patient Guide. A Winnipeg Health Region Hospital

Patient Guide. A Winnipeg Health Region Hospital Emergency Department Patient Guide Information FOR PATIENTS & Their FAMILIES in SEVEN OAKS GENERAL HOSPITAL s EMERGENCY DEPARTMENT A Winnipeg Health Region Hospital If You Have a Concern about Your Care,

More information

Barriers & Incentives to Obtaining a Bachelor of Science Degree in Nursing

Barriers & Incentives to Obtaining a Bachelor of Science Degree in Nursing Southern Adventist Univeristy KnowledgeExchange@Southern Graduate Research Projects Nursing 4-2011 Barriers & Incentives to Obtaining a Bachelor of Science Degree in Nursing Tiffany Boring Brianna Burnette

More information

HIPAA NOTICE OF PRIVACY PRACTICES

HIPAA NOTICE OF PRIVACY PRACTICES HIPAA NOTICE OF PRIVACY PRACTICES Marden Rehabilitation Associates, Inc. Marden Rehabilitation Associates of Ohio, Inc. Marden Rehabilitation Associates of West Virginia Health Care Plus Preferred Care

More information

OK to leave Messages?

OK to leave Messages? Jami Howell, Psy.D., LLC Licensed Clinical Psychologist 1215 SW 18 th Avenue, Portland OR 97205 p (503) 504-5222 f (503) 224-2134 jami@doctorjamihowell.com Client Information Name: Preferred Name: Date

More information

APPLICATION FOR ADDICTION COUNSELOR TRAINEE RECOGNITION OR ADDICTION COUNSELOR TRAINEE RENEWAL

APPLICATION FOR ADDICTION COUNSELOR TRAINEE RECOGNITION OR ADDICTION COUNSELOR TRAINEE RENEWAL Board of Addiction and Prevention Professionals (BAPP) 3101 West 41 st Street, Suite 205, Sioux Falls, SD 57105 Phone: 605-332-2645 Fax: 605-332-6778 Email: bapp@midconetwork.com Web: www.dss.sd.gov/bapp

More information

Marci Danielson, M.S., LMFT COUNSELING GUIDELINES, RIGHTS AND RESPONSIBILITIES

Marci Danielson, M.S., LMFT COUNSELING GUIDELINES, RIGHTS AND RESPONSIBILITIES COUNSELING GUIDELINES, RIGHTS AND RESPONSIBILITIES The mission of the counselors at Synchronicity Counseling is to offer a holistic, nonjudgmental approach to therapy with an understanding that all human

More information

Guidelines for Parenting Coordination FOREWORD

Guidelines for Parenting Coordination FOREWORD BC PARENTING COORDINATORS ROSTER SOCIETY Guidelines for Parenting Coordination FOREWORD These Guidelines for Parenting Coordination in British Columbia ( Guidelines") have been developed from the Guidelines

More information

State of Utah Department of Commerce Division of Occupational and Professional Licensing

State of Utah Department of Commerce Division of Occupational and Professional Licensing State of Utah Department of Commerce Division of Occupational and Professional Licensing Official Use Only Number: Date Approved/Denied: Approved/Denied By: Psychologist APPLICANT INFORMATION Full Legal

More information

Dermatology Associates of KY, PSC Job Description

Dermatology Associates of KY, PSC Job Description Dermatology Associates of KY, PSC Job Description Job Title: Perioperative R.N. Department: Ambulatory Surgery Center Reports To: ASC Manager FLSA Status: Non-Exempt;Hourly; Full-Time Summary Responsible

More information

REGISTERED NURSES 2012

REGISTERED NURSES 2012 Executive Office of Health and Human Services HEALTH PROFESSIONS DATA SERIES REGISTERED NURSES 2012 Deval L. Patrick, Governor John W. Polanowicz, Secretary Cheryl Bartlett RN, Commissioner September 2014

More information

Associate Degree in Nursing Program Application for Admission. DEADLINE FOR FALL 2016 SEMESTER: April 1, 2016 BY 11:00 AM

Associate Degree in Nursing Program Application for Admission. DEADLINE FOR FALL 2016 SEMESTER: April 1, 2016 BY 11:00 AM DEADLINE FOR FALL 2016 SEMESTER: April 1, 2016 BY 11:00 AM INSTRUCTIONS FOR NEW APPLICANTS Deadline April 1 by 11:00 AM 1. Complete the application. Download the application from www.goodwin.edu/majors/nursing/default.asp

More information

BATTERER INTERVENTION PROGRAM APPLICATION FOR PROVIDERSHIP

BATTERER INTERVENTION PROGRAM APPLICATION FOR PROVIDERSHIP BATTERER INTERVENTION PROGRAM APPLICATION FOR PROVIDERSHIP Date: / / Name of Program: Address: Telephone Number: ( ) Fax Number: ( ) Email Address: Areas To Be Served: (Counties or Cities) TERMS AND CONDITIONS:

More information

Summary of the State Elder Abuse. Questionnaire for Vermont

Summary of the State Elder Abuse. Questionnaire for Vermont Summary of the State Elder Abuse Questionnaire for Vermont A Final Report to: Vermont Adult Protective Services February 2002 Prepared by Researchers at The University of Iowa Department of Family Medicine

More information

Living Through a Sentinel Event Crisis: Lessons Learned from the David Arndt, MD Case

Living Through a Sentinel Event Crisis: Lessons Learned from the David Arndt, MD Case Page 1 6th Annual NPSF Patient Safety Congress Let s Get On With It! May 3-7, 2004 Hynes Convention Center Boston, MA Living Through a Sentinel Event Crisis: Lessons Learned from the David Arndt, MD Case

More information

1995 Somatic Practices Survey Results

1995 Somatic Practices Survey Results 1995 Somatic Practices Survey Results A report from the California Coalition on Somatic Practices (CCSP) December, 1995 In January of 1995, the California Coalition on Somatic Practices (CCSP) printed

More information

APPLICATION FOR PRIVATE ACADEMIC SCHOOL TEACHING CERTIFICATE FORM PDE 4536 (Refer to instructions included with this two page form)

APPLICATION FOR PRIVATE ACADEMIC SCHOOL TEACHING CERTIFICATE FORM PDE 4536 (Refer to instructions included with this two page form) APPLICATION FOR PRIVATE ACADEMIC SCHOOL TEACHING CERTIFICATE FORM PDE 4536 (Refer to instructions included with this two page form) PDE USE ONLY CONTROL NO. APPLICANTS: Please note the following information

More information

Director of Rehabilitation Services. Location/Department: Therapy Clinic Date Developed: 02/26/14 Date of this Revision: 2/11/15 Reports To: CEO

Director of Rehabilitation Services. Location/Department: Therapy Clinic Date Developed: 02/26/14 Date of this Revision: 2/11/15 Reports To: CEO Director of Rehabilitation Services Location/Department: Therapy Clinic Date Developed: 02/26/14 Date of this Revision: 2/11/15 Reports To: CEO Supervisory Responsibilities: Directly supervises therapy

More information

Accident Claim form (W)

Accident Claim form (W) Accident Claim form (W) Policy no Claim no Full name Customer Account Number Combined Insurance seeks to pay all genuine claims. We check all claims carefully to identify fraudulent or exaggerated claims.

More information

Survey on EHR/CPOE for Geisinger ICU Physicians, PAs and NPs

Survey on EHR/CPOE for Geisinger ICU Physicians, PAs and NPs Center for Quality and Productivity Improvement University of Wisconsin-Madison Survey on EHR/CPOE for Geisinger ICU Physicians, PAs and NPs 1 year after the implementation Letter to Geisinger Intensive

More information