Demographics

Select Fewer than 100 beds 100 to 299 beds 300 to 499 beds 500 beds and over

2. Please check the one category that best describes the type of organization that is responsible for establishing policy for the overall operation of your hospital.

Select State and local government Non-government, not-for-profit Investor-owned, for-profit Military Veterans Affairs US Public Health Service Other Other:

To which branch of the service does your hospital belong?
Select Army Navy Air Force

Select General medical and surgical Psychiatric Rehabilitation Specialty: Pediatric Specialty: Oncology Other Other:

4. Does your hospital provide venous duplex ultrasound imaging services 24 hours per day and 7 days per week?
Yes No

5. Does your hospital have a physician residency-training program that has been approved by the Accreditation Council for Graduate Medical Education?

Yes No

If Yes do you offer a medical residency in the following specialties? (check all that apply)
Emergency Medicine
Hematology
Hematology/Oncology

6. Does your hospital have a pharmacy residency-training program that has been accredited by the American Society of Health-System Pharmacists?

Yes No

7. Does your organization have an inpatient antithrombosis team to manage patients with complicated thrombotic episodes?

Yes No

If yes, does the team include the following types of healthcare providers? (check all that apply)
Physician
Pharmacist
Nurse
Dietician
Laboratory Technician
Patient Educator

8. Does your hospital have an outpatient anticoagulation service/clinic affiliation?

Yes No

If yes, is the clinic/service staffed with the following healthcare providers? (check all that apply)
Physician
Pharmacist
Nurse
Dietician
Laboratory Technician
Patient Educator

Select None Amerinet Broadlane Consorta Department of Defense HCA HSCA Premier Purchase Connection Veterans Affairs VHA/Novation UHC/Novation Other Other:

10. Please check the one category that best describes the location of your hospital.

Urban Rural

Is your hospital a critical access hospital? (Optional)
Yes No

Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virgin Islands Vermont Virginia Washington West Virginia Wisconsin Wyoming Non US Country US Military Foreign

12. Have you completed the 2004 ISMP Medication Safety Self Assessment® for Hospitals? (Optional)

Yes No