MITSS Clinician Survey 2

This CONFIDENTIAL survey will help MITSS better serve you and others enduring the stress after an adverse event. There are 14 questions included in this survey. Your participation is greatly appreciated. This is a CONFIDENTIAL survey that will take approximately 5 to 10 minutes to complete. Please feel free to answer openly and honestly as your responses will help MITSS to provide information and support more effectively.

1. Are you male or female?

Are you male or female? Male

Female

2. Age?

Age?

3. What role did you have in the event?

What role did you have in the event? I was a physician involved.

I was a nurse involved.

I was a pharmacist involved.

I was a mental health worker involved.

Other (please specify)

4. What type of an event was it?

What type of an event was it? Surgical

Medication

Misdiagnosis

Other (please explain as much as possible regarding the nature of the event and what went wrong, as if speaking to lay people)

5. When did the event occur?

When did the event occur?

6. Were you referred to confidential support services?

Were you referred to confidential support services? Yes

7. If yes, what services were you offered?

If yes, what services were you offered? Individual Therapy

Group Therapy

Phone Counseling

Medication to assist with emotional control

Peer Support

Other (please specify)

8. Were you referred to services at the place the event occurred (in house) or were you referred to outside services?

Were you referred to services at the place the event occurred (in house) or were you referred to outside services? In House Support

Ouside Support

Other (please specify)

9. Please check any of the following you have experienced/ are experiencing after the event.

Please check any of the following you have experienced/ are experiencing after the event. Changes in appetite Anxiety Changes in energy level Substance abuse Depression Difficulty concentrating	Frequent bouts of crying Difficulty relating to peers at work (please explain under 'other') Financial stress Thoughts of suicide Professional difficulties (please explain under 'other') Problems with personal relationships	Loss of interest in previously enjoyable activities Changess in sleep patterns Feelings of guilt Difficulties trusting others (please explain under 'other')
Other (please specify)

10. Please indicate any of the following you have experienced in the past 3 months, not otherwise explained by a known medical condition:

Please indicate any of the following you have experienced in the past 3 months, not otherwise explained by a known medical condition: Tightness in the chest

Heart racing/ pounding

Shortness of breath

Feeling lightheaded

Indigestion

Sweaty palms

Hot/ cold sweats

Inability to relax

11. Please indicate any of the following that you have experienced in the past 12 months:

Please indicate any of the following that you have experienced in the past 12 months: Attempts to avoid reminders of the event

Smells,sounds, places, people, etc. that trigger anxiety related to the event

Feeling afraid

Intrusive thoughts of the event

Feeling an intense awareness of situations or surroundings, as if your senses are in overdrive

Disturbing dreams of the event

Feelings of helplessness

12. After the event, were you able to take a work-sanctioned break to regroup prior to caring for others?

After the event, were you able to take a work-sanctioned break to regroup prior to caring for others? Yes

13. Please feel free to add any additional information you would like to share with MITSS, including any feedback regarding this survey or your personal event.

Please feel free to add any additional information you would like to share with MITSS, including any feedback regarding this survey or your personal event.

14. If you would like a MITSS support staff to contact you, please leave your contact information below. This survey does not automatically record any identifying or contact information. Therefore, it is important that you leave such confidential information in order for a support staff member to contact you.

If you would like a MITSS support staff to contact you, please leave your contact information below. This survey does not automatically record any identifying or contact information. Therefore, it is important that you leave such confidential information in order for a support staff member to contact you.

1. General Information

1. Are you male or female?

2. Age?

3. What role did you have in the event?

4. What type of an event was it?

5. When did the event occur?

6. Were you referred to confidential support services?

7. If yes, what services were you offered?

8. Were you referred to services at the place the event occurred (in house) or were you referred to outside services?

9. Please check any of the following you have experienced/ are experiencing after the event.

10. Please indicate any of the following you have experienced in the past 3 months, not otherwise explained by a known medical condition:

11. Please indicate any of the following that you have experienced in the past 12 months:

12. After the event, were you able to take a work-sanctioned break to regroup prior to caring for others?

13. Please feel free to add any additional information you would like to share with MITSS, including any feedback regarding this survey or your personal event.