Neonatal and Pediatric Transport Team Database
~ Questionnaire ~

Please complete the following.
1. Name of the sponsoring institution:
2. Type of pediatric transport team:
Unified Team (one team performs pediatric and neonatal transports)
Specialized Pediatric Transport Team (pediatric transports only)
Specialized Neonatal Transport Team (neonatal patients only)

Other
3. Pediatric Team Medical Director's name:
Phone #:
4. Neonatal Team Medical Director's name:
Phone #:
5. Pediatric Team Nurse Manager's name:
Phone #:
6. Neonatal Team Nurse Manager's name:
Phone #:
7. Emergency phone number to access team:
8. Subspecialty Pediatric/Neonatal services available at sponsoring institution--list all that apply:
9. Percent of each mode of transport provided:
% Ground
% Helicopter
%
Fixed Wing
10. Average number of transports performed yearly:
11. Are physicians used on the transport team? Yes No
If yes, what type(s) of physicians? Check all that apply.
Full-time
Part-time
Attending
Resident

Thank you for your participation.

01/09