Please fully complete survey with most current data available. Questions may be addressed to
Kate McDonough at 630.495.6400, ext. 205, or katem@icep.org.

Emergency Department Contact Information

1. * Hospital Name

2. * Hospital Address

3. * Hospital Phone Number

4. * Emergency Department Direct Phone Line

5. ED Fax

6. ED Email

Emergency Department Personnel

Please enter the full name and credentials (ex., MD, DO, RN) of the individual who holds each position.

7. * Emergency Department Director (physician)

8. * Emergency Department Nurse Manager

9. Resource Director

10. EMS Medical Director

11. EMS Coordinator

12. Research Director

13. Research Coordinator

14. Bioterrorism Medical Director

15. Bioterrorism Coordinator

Emergency Department Census Data and Statistics

16. * What are the hospital's designation(s) / classification(s)? (Please check all that apply)
 Level I Trauma Center
 Level II Trauma Center
 EMS Resource Hospital
 EMS Associate Hospital
 EMS Participating Hospital
 Regional POD Hospital
 Emergency Department Approved for Pediatrics (EDAP)
 Standby Emergency Department Approved for Pediatrics (SEDAP)

17. What EMS region of the state is the hospital located in?
Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Region 9 Region 10 Region 11

18. * Number of Emergency Department Beds

19. Number of Emergency Department Visits in 2002:

20. Number of Emergency Department Visits in 2003:

21. Number of Emergency Department Visits in 2004:

22. Number of Emergency Department Visits in 2005:

23. * Emergency-department visit figures represent:
 Calendar year data
 Fiscal year data

24. Do the emergency-department visit figures include Fast Track patients?
 Yes
 No

Emergency Department Services

25. * Available emergency department services and specialized facilities: (Please check all that apply)
 Separate Pediatric Emergency Department
 Fast Track
 Observation Unit
 Detox Unit
 Burn Unit
 Cardiac Cath Lab
  Open Heart Capacity
  Stroke Center
  Hyperbaric Chamber
  Decontamination Capacity
  Dedicated Radiology Area/Equipment
 Transport Team
  Helicopter Transport
  NICU
  PICU
  Negative-Pressure Isolation Room
  In-patient Psychiatric Facility
  Obstetric Facility
  Emergency Ultrasound
  ENT Emergencies
  Ophthalmalogic Emergencies
  Orthopedic Emergencies
  24-hour Dentist
  MERCI Radio
  Other(s), please list:

26. Who treats children in your ED? (Please check all that apply.)
  Emergency Physicians
  Pediatricians
  Pediatric Emergency Physicians

Survey Respondent Contact Information

27. * Name of Person Completing This Survey

28. * Contact Phone Number