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Kansas Initiative for Stroke Survival - Stroke Ready Hospitals

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1. Survey Completion Date (today's date)

Date / Time - Survey Completed

Date

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2. Contact Name for Questions Related to Survey Data

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3. Facility Name

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4. Other Facility Name

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5. Patient Age

Age in Years

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6. Hispanic Ethnicity

Yes

No

Unknown

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7. Patient Race

American Indian/Alaska Native

Black or African American

White

Asian

Native Hawaiian/Pacific Islander

Other

Unknown

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8. Patient Gender

Male

Female

Unknown

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9. Did you use the 24/7 Stroke Support Line?

Yes

No