Recruitment Survey

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Thank you for your interest in the MOC 4 Pediatric Disaster Preparedness Project. Email hfitzpatrick@aap.org with any questions.

Please review the PowerPoint below and answer the following questions in this survey.

After reviewing the presentation and if you decide to participate in this MOC 4 Initiative, complete the registration survey. An email will be sent to you after the completion of this survey, which will prompt you to work with your team to complete the initial Environmental Scan. This scan is a requirement of your participation and will be your baseline pediatric disaster preparedness score for the initiaitve.

The deadline for completion of the initial environmental scan is Monday, October 31, 2022.

Thank you for your participation.

MOC PowerPoint Description - Please Review Prior to Registration

Attachment:MOC 4 Project Overview-Hospitals v.2.0 FINAL.pptx

Do you think you'll be able to complete the project in 6 months and finish the required amount of responsibility to be considered prepared for a disaster? Please review the PowerPoint overview slides prior to answering.

**The deadline for completion of the initial Environmental Scan is October 31, 2022**

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Yes

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Please provide feedback as to why you do not believe that you can complete the project in 6 months and finish the required amount of responsibility to be considered prepared for a disaster.

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Your Name

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Your Email

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Hospital

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Location

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Department (ex, Pediatrics):

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Section (ex, Pediatric Nephrology):

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Tell us about your staff within your section (example: 2 MDs, 4 RNs)

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Do you only see children?

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Yes

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How many children does your section see a day?

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Any physicians that want to receive credit need to fill out this recruitment survey. This recruitment survey serves as an individual enrollment for that physician. From there, your section can just fill out the environmental scans on one person's survey queue for the whole team.

Identify lead members within your practice that would want to participate

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How many RNs?

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How many medical assistants?

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How many physicians?

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How many advanced practice providers?

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How many clinical managers?

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How many practice administrators?

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