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* 1. Please provide the following information:

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* 2. Please provide the following information (optional):

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* 3. Type of Hospital (Check all that apply.)

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* 4. Number of Beds

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* 5. How many operating rooms are in your facility?

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* 6. Do you have an automated Anesthesia Electronic record system?

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* 7. Do you have an institutional Electronic medical record system (EMR)?

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* 8. Is there an electronic medical record system (computerized records) in any of the following areas? Please check all that apply.

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* 9. Do you have a Mechanism for dissemination for identified Difficult Airway patients?

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* 10. If you answered "Yes" to Question #9, please mark all that apply:

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* 11. Do you have a department policy regarding the mechanism for dissemination for identified Difficult Airway patients?

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* 12. If you answered "Yes" to Question #11, please mark all that apply:

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* 13. Which of the following does your facility/hospital define as a Difficult Airway? Please check all that apply.

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* 14. Do you have a form letter regarding difficult airway to give to patient?

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* 15. Where are Difficult Airway patients determined? Please check all that apply.

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* 16. Do you have a temporary ID bracelet for Difficult Airway for the patient while in the hospital?

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* 17. If you answered "Yes" to Question #16, please check all that apply:

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* 18. Do you have a point person for the Difficult Airway information at your institution?

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* 19. Do you have a patient-alert system for rapid identification of a known Difficult Airway patient when they are in your institution?

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* 20. If you answered "Yes" to Question #19, please check all that apply:

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* 21. Please check all airway equipment currently used or available.

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