ASA Practice Survey
Please tell us some select information about your practice.
Name of Anesthesia Practice or Department:
Is the above Practice or Department a component or
affiliate of a larger anesthesia practice?
Yes
No
Unknown
Ownership of the practice:
(Check all that apply.)
Private Practice
Public Company
Facility-Owned
Veterans Administration
University/Academic Institution
Military
Other
Location of primary business or departmental office:
Address:
City:
State:
Zip Code:
State(s) in which the practice provides patient care:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Does your group have its own Political Action Committee?
Yes
No
Unknown
Does your group encourage providers to be members of the American Society of Anesthesiologists Political Action Committee?
Yes
No
Unknown
Enter approx. percentage of ASAPAC
membership among practice physicians:
 
Does the practice employ its own lobbyist?
Yes
No
Unknown
Does your group require or encourage physicians to be members of American Society of Anesthesiologists?
Yes
No
Unknown
Enter approx. percentage of ASA
membership among practice physicians :
Does the practice utilize in-house billing?
Yes
No
Unknown
Does the practice have a centralized Quality Department?
Yes
No
Unknown
Does the practice have centralized Risk Management?
Yes
No
Unknown
Training Programs:
(Check all that apply.)
Own-facility sponsored residents or fellows program
Visiting residents or fellows program
ACGME-accredited Core Residency Program
AOA-accredited Core Residency Program
Non-accredited Core Residency Program
Subspecialty fellowship program
Anesthesiologist Assistants programs
Nurse Anesthetists programs
None
Approximate total number of facilities served:
(Check all that apply.)
University Hospitals
Community Hospitals
Specialty Hospitals
Free-Standing Surgery Centers
Pain Clinics
Office-Based Anesthesia
Other
Does the practice utilize an Electronic Medical Record?
Yes
No
Unknown
Does the practice utilize an Anesthesia Information Management System?
Yes
No
Unknown
Enter name of Anesthesia Information
Management System:
Enter percentage of anesthetic cases
done using an electronic medical record:
Does the practice participate in anesthesia research?
Yes
No
Unknown
Does the practice contribute data to the Anesthesia Quality Institute?
Yes
No
Unknown
Enter percentage of anesthetic
cases participating in AQI:
Approximate number of personnel employed:
Physician anesthesiologists:
  
Nurse anesthetists:
  
Anesthesiologist assistants:
  
Hospitalists:
  
Intensivists:
  
Pain Medicine Physician:
  
Contact information for physician or administrative executive:
Contact Full Name:
Contact Email:
Please provide feedback regarding your thoughts on American Society of Anesthesiologists:
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Email: airs@asahq.org