From EMT Education Consortium:



1. What is your agency's name?

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2. What is your name ?

| |

3. What is your title?

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4. What is your phone number?

3-digit area code and number

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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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