HELP THE CAUSE

Professional Title

Level of Care

Normal Ratio

Surged Ratio

How Often do you Surge?

Which shift?

Days

Nights

Other

Facility Name

City

State

How burned out are you?

Not at all

Somewhat burned out

Moderately burned out

Severely burned out

Complete lack of empathy/emotion

Would you recommend your own family be treated at your hospital?

Yes

No

Sometimes

I work with adequate:

RNs/LPNs

Patient care techs/CNA

Respiratory Therapists

Case Managers

Physical Therapists

Occupational Therapists

Speech Therapists

Housekeepers

IT Support

Physicians

Comments

Thank you for your contribution

bottom of page