Family Satisfaction in the Intensive Care Unit Questionnaire: FS-ICU 24R

FS-ICU 24R - Site Registration Form

For the fillable text forms, please avoid using accents (e.g. “ô”) or any special characters (e.g. “/”), with the exception of a hyphen (“ -”).
Required fields are marked with a red asterisk (*)

For instructions on completing this form click here

* 1. Primary REDCap Users (Usernames and passwords to access the online data entry system will be assigned to each of the individuals listed below.)

First name	Last name	Email	Telephone	Role in ICU

To register your site, please provide the following information.

Hospital Information
* 1. Hospital Name:
* 2. Type of Hospital:	Teaching Non-Teaching
* 3. City:
4. Province/State:
* 5. Country:	Canada United States -------------------------------------------------- AfghanistanÅLand IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia And HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic Of TheCook IslandsCosta RicaCote D'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran, Islamic Republic OfIraqIrelandIsle Of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People'S Republic OfKorea, Republic OfKuwaitKyrgyzstanLao People'S Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, The Former Yugoslav Republic OfMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States OfMoldova, Republic OfMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre And MiquelonSaint Vincent And The GrenadinesSamoaSan MarinoSao Tome And PrincipeSaudi ArabiaSenegalSerbia And MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia And The South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard And Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic OfThailandTimor-LesteTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis And FutunaWestern SaharaYemenZambiaZimbabwe
* 6. Size of hospital (number of beds):

ICU Information

* 7. Does your hospital have multiple ICUs?	Yes No
* 8. ICU name (Max 120 characters):
* 9. ICU type:	Open (Attending physician remains in charge, ICU physician consults) Closed (Care transferred or shared with ICU physician) please specify
* (please specify)
* 10. Case Types: (check all that apply)	Medical Neurological Surgical Neurosurgical Trauma Cardiac Surgery Pediatrics Burns Other, please specify
* 11. Is there a designated ICU Medical Director?	Yes No
* 12. Number of staffed beds in ICU:
* 13. Number of ICU admissions per year:
* 14. Presense of an in-house intensivist 24h/d ?	Yes No
* 15. Number of patients per nurse:

* Checking this box:

1. indicates that you have had the opportunity to read information about the survey and understand the purpose of the Family Satisfaction in the Intensive Care Unit Questionnaire: FS-ICU 24R.
2. indicates you agree to share your de-identified data so that it can be compiled into a larger dataset which will be used to generate bench-marked site reports.
3. indicates that you agree to administer the survey based off the standards set in our instructions.

For instructions on using REDCap and our surveys: click here

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