COPPER Application

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Please complete this application for COPPER recognition of your hospital's emergency department. If you have any questions, contact Nicolena Mitchell at nicolena.mitchell@cuanschutz.edu.

Thank you!

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Name of person completing the application (i.e., the "Applicant")

* must provide value

Applicant credentials

Applicant email

* must provide value

Applicant phone number

* must provide value

Hospital name

* must provide value

Hospital street address

* must provide value

Hospital city

* must provide value

Hospital zip code

* must provide value

What level of COPPER recognition is your facility applying for?

* must provide value

Pediatric Prepared

Pediatric Advanced

To be determined

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What is the annual total patient (adult and pediatric) volume of your emergency department (ED)?

* must provide value

Low: < 10,000 patients per year

Medium: 10,000 - 49,999 patients per year

Medium-High: 50,000 - 74,999 patients per year

High: >= 75,000 patients per year

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What is the annual pediatric (as defined by your hospital) patient volume in your ED?

* must provide value

Low: < 1,800 pediatric patients (average of 5 or fewer per day)

Medium: 1,800 - 4,999 pediatric patients (average of 6 - 13 per day)

Medium-High: 5,000 - 9,999 pediatric patients (average of 14 - 26 per day)

High: >= 10,000 pediatric patients (average of 27 or more per day)

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How is your hospital best classified?

* must provide value

Children's Hospital

Community Hospital

Comprehensive Community Hospital

Critical Access Hospital

Other

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You selected 'Other" above. How would you describe your hospital?

Please select the categories that apply to your hospital's setting (select all that apply)

* must provide value

Remote / Frontier

Rural

Suburban

Urban

Please indicate your hospital's state designated trauma level

* must provide value

What electronic medical record (EMR) system does your hospital use?

* must provide value

You answered 'Other' above. What electronic medical record (EMR) system does your hospital use?

Are there any inpatient services that accept pediatric patients (e.g., adult inpatient unit, adult intensive care unit, neonatal intensive care unit, newborn nursery, pediatric inpatient unit and/or pediatric intensive care unit)?

* must provide value

Yes

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Which of the following inpatient services at your hospital have the ability to admit children?

* must provide value

Adult inpatient unit

Adult intensive care unit

Neonatal intensive care unit

Newborn nursery

Pediatric inpatient unit

Pediatric intensive care unit

Other

You checked 'Other' above. What other inpatient services at your hospital have the ability to admit children?

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.