Thank you for attending the Pediatric Safe Transport in Ambulances training sponsored by the Pennsylvania Traffic Injury Prevention Project. Your feedback will help us to improve future events.

*1.First Name(Required.)

*2.Last Name(Required.)

*3.Date of Birth(Required.)

*4.EMS Certification Level or Profession (If not an EMS Provider)(Required.)

Emergency Medical Responder (EMR)

Emergency Medical Technician (EMT)

Advanced Emergency Medical Technician (AEMT)

Paramedic

Registered Nurse (RN)

Pre-Hospital Registered Nurse (PHRN)

Physician Assistant (PA)

Pre-Hospital Physician Extender (PHPE)

Physician 

Pre-Hospital Physician (PHP)

Law Enforcement

Injury Prevention Professional

Other (please specify)

5.PA EMS Certification Number (if applicable)

*6.Are you a certified Child Passenger Safety Technician?(Required.)

Yes

No

7.Child Passenger Safety Technician Number (if applicable)

*8.County of Residence(Required.)

*9.Overall, how would you rate the event?(Required.)

Excellent

Very good

Good

Fair

Poor

*10.Upon completion of this class I am better able to:(Required.)

*11.What did you like about the event?(Required.)

*12.What did you dislike about the event?(Required.)

*13.How organized was the event?(Required.)

Extremely organized

Very organized

Somewhat organized

Not so organized

Not at all organized

*14.Was the event length too long, too short or about right?(Required.)

Much too long

Too long

About right

Too short

Much too short

15.Additional Comments