From EMT Education Consortium:
1. What is your agency's name?
| |
2. What is your name ?
| |
3. What is your title?
| |
4. What is your phone number?
3-digit area code and number
| |
6. What is your rank/position?
( Chief ( Recruitment Supervisor
( Other:
7. What is your certification level? Do not choose more than two of the following
( Fire Fighter ( First Responder
( EMT Basic ( EMT Intermediate
( EMT Paramedic ( Other
8. Which of the following best describes your agency? Select one
( Paid agency ( Volunteer
( Mixture (Both paid and volunteer)
( Private Industry
9. Are you a 9-1-1 public response agency?
( Yes ( No
10. How many personnel work in your agency (total, including non emergency and emergency staff)?
| | | | |
11. What duties do your emergency response personnel typically perform for your agency? Select all that apply
( EMS ( Fire
( Other (If other, describe in box below.)
|1. |
|2. |
12. What is your primary funding source? Select one
( Public ( Private ( Tax Levy
( Subscription Service ( Other:
13. Please complete the following chart to most accurately describe your agency type.
| |YES |NO |
|Fire Agency |( |( |
|EMS Agency |( |( |
|Transport Agency |( |( |
|Non Transport Agency |( |( |
14. Do personnel at your agency have access to conflict resolution or mediation services?
( Yes ( No
15. What commitments do you require of personnel in addition to training? Check all that apply
( Monthly Continuing Education ( Call Schedule
( Residency Requirements
( Other:
16. Please complete the following chart to most accurately describe your current staffing level.
| | Number of |Number of |
| |Paid Staff |Non Paid Staff |
|Basic EMT | | |
|Intermediate EMT | | |
|Paramedic EMT | | |
|First Responder EMT | | |
|Driver | | |
|Other | | |
17. Please complete the following chart for the past 12 months.
| |Number of Newly |Number of Recertified |
| |Certified | |
|Basic EMT | | |
|Intermediate EMT | | |
|Paramedic EMT | | |
|First Responder | | |
|Other | | |
18. Does your agency have a recruitment and retention plan?
( Yes ( No
19. Does your agency work cooperatively with other agencies to recruit personnel?
( Yes ( No
If yes go to Number 20; if no go to Number 21.
20. What activities did you engage in with other agencies to recruit personnel? Check all that apply ( Shared costs ( Media campaign
( Combined training ( Other:
21. How much does your agency spend on recruiting activities per year?
( $0-$99 ( $100 - $499
( $500-$999 ($1,000 or more
22. What are the five most successful methods your agency uses to recruit personnel?
|1. |
|2. |
|3. |
|4. |
|5. |
23. What are the five major recruiting barriers for your agency?
|1. |
|2. |
|3. |
|4. |
|5. |
24. To what extent does each one of the following Agency factors contribute to your agency's ability to retain personnel? Minor Major
Factor Factor
|Factors |1 |2 |3 |
|Lack of emotional support from agency coworkers | | | |
|Effort is not valued by agency | | | |
|Personality issues at agency | | | |
|Lack of respect from physicians | | | |
|Lack of respect from nurses | | | |
|On-call expectations | | | |
|Lack of opportunity to participate at agency | | | |
|Lack of independence | | | |
|Must also be a firefighter | | | |
|Must participate in firefighting | | | |
|Response location | | | |
|Response time requirements | | | |
|Lack of internal structured training program | | | |
|Sufficient similarly certified EMS personnel | | | |
|Lack of adequate EMS equipment | | | |
|Amount of critical incident stress | | | |
|Poor critical incident stress debriefing | | | |
|Physical demands of EMS work | | | |
|Shortage of personnel for backup | | | |
|Health and/or safety hazards | | | |
|Legal liability | | | |
|Lack of leadership | | | |
25. To what extent does each one of the following Personal factors contribute to your agency's ability to retain personnel?
Minor Major
Factor Factor
|Factors |1 |2 |3 |
|Lack of support from non-agency employer | | | |
|Difficulty getting time off from employer for | | | |
|emergency calls | | | |
|Lack of support from non-agency coworkers | | | |
|Out of pocket expenses to volunteer | | | |
|Employment schedule/shift work | | | |
|Time commitment at agency | | | |
|Lack of wage/salary compensation during call time| | | |
|Transportation issues interfere with agency | | | |
|participation | | | |
|Child/Elder care issues interfere with agency | | | |
|participation | | | |
|Family obligations other than child/elder care | | | |
|interfere with agency participation | | | |
|Lack of family support interferes with agency | | | |
|participation | | | |
|Community not supportive of EMT to participate | | | |
|with agency | | | |
|Personal health interferes with agency | | | |
|participation | | | |
26. To what extent does each one of the following Education/Training factors contribute to your agency's ability to retain personnel?
Minor Major
Factor Factor
|Factors |1 |2 |3 |
|Availability of education | | | |
|Location for education/training not convenient | | | |
|Lack of transportation interferes with | | | |
|education/training | | | |
|Cost of education/training interferes with | | | |
|education/training | | | |
|No opportunity to use advanced education | | | |
|Child/Elder care issues interfere with agency | | | |
|participation | | | |
|Family obligations other than child/elder care | | | |
|interfere with education/training | | | |
|Family not supportive of EMT pursuing | | | |
|education/training | | | |
|Community not supportive of EMT pursuing | | | |
|education/training | | | |
|Community not supportive of EMT participating | | | |
|with agency | | | |
|Personal health interferes with | | | |
|education/training | | | |
27. What are the three most successful methods your agency uses to retain personnel?
|1. |
|2. |
|3. |
28. To what extent does each one of the following factors contribute to the local community college's inability to meet needs for training?
Minor Major
Factor Factor
| |1 |2 |3 |
|Classes not conveniently located | | | |
|Lack of quality instruction | | | |
|Class scheduled at wrong time of year | | | |
|Class times not convenient | | | |
|Cost | | | |
|Other (Describe): | | | |
29. What method(s) do you use to obtain continuing education for your EMTS?
|1. |
|2. |
|3. |
|4. |
|5. |
30. Please indicate your order of preference for the following types of educational opportunities. Rank from most preferred = 9 to least preferred = 1
|Rank |Type of educational opportunity |
|(1-9) | |
| |Hands on skills practice |
| |Classroom |
| |Video |
| |Interactive televideo |
| |Internet |
| |CD or DVD |
| |Correspondence |
| |DHS EMS Mobile Training Unit |
| |Other (please name): |
31. What does your agency pay for to become qualified to work or to volunteer?
| |Yes |No |
|Initial education | | |
|Testing fees | | |
|Initial certification | | |
|Recertification | | |
|Continuing education | | |
32. Does your agency pay for training outside your agency after initial certification?
( Yes ( No
33. Please complete the following chart for personnel training to become certified in the following categories.
| |Number of Personnel Currently |
| |in Training |
|Basic EMT | |
|Intermediate EMT | |
|Paramedic EMT | |
|First Responder | |
|Other (Describe) | |
34. How far is your agency willing to have personnel travel for certification education/training?
( 1-15 minutes ( 15-30 minutes
( 30-45 minutes ( 45- 60 minutes
( 1-2 hours ( 2 or more hours
35. How far is your agency willing to have personnel travel for continuing education/training?
( 1-15 minutes ( 15-30 minutes
( 30-45 minutes ( 45- 60 minutes
( 1-2 hours ( 2 or more hours
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