Institution:
Residency Training Program:
Site Administrator*:
Administrator E-mail:
Administrator Phone:

(form continues, please scroll down)

* Site Administrator :

Each training program will have one Site Administrator (preferably a PICU Attending) who will be provided a site-specific log-on and password by SCCM. This log-on and password will allow access to the "Admin" area of the exam where they can sign up their housestaff to take the exam. For this, the Site Administrator will need the full name and e-mail address of the resident/trainee. Once signed up for the exam by the local site administrator, the trainee will receive a message directly from the system providing him/her with a unique log-on and password with instructions on accessing the examination. The Site Administrator will also be able to view the performance/results of their trainees on the “Admin” area of the site. Once a database is functional, they will also be able to compare performance of their housestaff relative to their national peer group.

Protecting the log-on and password to the Admin area and preventing compromise of the content of the examination are the responsibility of the Site Administrator. Please contact SCCM (CONTACT INFO HERE) immediately if there has been a breach of security at your site.

1.  Number of PICU and intermediate care beds

< 10
11-20
21-30
>30

2.  Number of pediatric beds within institution

<100
100-200
201-300
300

3.  Type of facility

Pediatric center within a large (adult+pediatric) teaching hospital
Free-standing Children's Hospital
County Hospital

4.  Number of pediatric residents per year in training program

< 10
11-20
21-30
>30

5. Number of medicine/pediatric residents per year in training program

< 10
11-20
>20
No Med/Peds residents

6. Does your institution have an accredited Pediatric Critical Care Fellowship training program?

yes
no

7.  If answer to # 6 Yes, total number of PICU Fellows in training for current academic year

0
1-3
4-6
7-9

8.  SCHEDULED night-time and weekend IN-HOUSE coverage for the PICU is provided by:

Fellows only
Attending Physicians only
Fellows OR Attendings are present in-house (varies by call schedule)
Neither Fellows NOR Attendings stay in-house (residents only)

9.  Which of the following types of patients do you care for in your Unit? Please check all that apply:

Cardiovascular surgical patients
Trauma patients
Solid organ transplant recipients
Bone marrow transplant recipients
Surgical subspecialty patients
ECMO patients

10.  Number of attending-level physicians with PICU clinical service responsibilities:

1-3
4-6
7-9
>9

11.  Number of nurse practitioners with clinical service responsibilities in PICU

No Nurse Practitioners in our PICU
1-2
3-5
>5

12.  Number of residents on-service in PICU per month:

1-2
3-4
>4

13. Number of residents on-call in PICU at night

1
2
>2

14.  Does your PICU rotation program currently comply with the RRC 80 hour workweek residency training restriction?

Yes, already does comply
No
In process of being restructured to comply

15. Does your program have a formal didactic lecture series addressing PICU educational issues?

Yes
No

16.  If answer to #15 is Yes, in what setting are the lectures given?

During PICU rotation
Outside the PICU rotation

17.  Do you use the www.picucourse.org presentations (verbatim or as a template) for your didactic sessions with the residents ?

Yes
No

18. Approximate number of formal didactic sessions on PICU topics being administered per month by your PICU Faculty/Fellows:

None
1-3
4-6
7-10
>10

19.  Maximum number of patients a resident is expected to "carry" during the daytime in your PICU :

No pre=set maximum
<5
6-8
8-10
>10