Form 1460 EMS Agency Telephone Screening Form

OMB Control Number: 2127-XXX

Expiration Date: XX/XX/XXXX

Form 1460

The EMS Sleep Health and Fatigue Education Study

EMS Agency Telephone Screening Form

Under the Paperwork Reduction Act, a federal agency may not conduct or sponsor, and a person is not required to respond to collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control number. The OMB Control Number for this information collection is 2127-XXX (expiration date: MM/DD/YYYY). The average amount of time to complete this survey is 5 minutes. All responses to this collection of information are voluntary. If you have comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden send them to Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Ave, S.E., Washington, DC, 20590.

Thank you for your interest in this research study. In order to determine if you are eligible to participate, we need to ask you a few questions.

YES	NO	Question
		[1] Does your EMS agency provide EMS services (including 911 response and transport) in the United States, including Alaska or Hawaii?
		[2] Does your EMS agency provide ground-based EMS services 24-hours a day. Agencies limited to air-medical services only are not eligible?
		[3] Does your EMS agency employ between 50 and 300 EMS paid full-time and/or part-time clinicians/personnel? Agencies that use an all-volunteer staffing model are not eligible.
		[4] Does your EMS agency restrict the use of personal mobile phones/smartphones during shifts (other than when performing patient care or other critical tasks)?

For any NO responses, read this: “Thank you for your interest. You answered NO to at least one question. We will need to consult with the research study’s principal investigator to make a final determination of your agency’s eligibility. Do you have a preferred email address that we can use to contact you with the final decision? Email: _______________________________

If all responses are YES, then read the following: “We have determined that your EMS agency is eligible to participate in this research study.

What type of agency do you consider your organization? (e.g., fire-based, hospital-based, third service): ______________________________________________________________________.

Approximately how many dispatches did you experience in calendar year 2018? _____________.

Approximately how many transports did you complete in calendar year 2018? _______________.

How many of your employees are full-time? ____________.

How many of your employees are part-time? ____________.

How many of your employees are volunteer?____________.

Do you have a formal fatigue risk management program (YES or NO), if YES, please describe: __

______________________________________________________________________________.

______________________________________________________________________________.

______________________________________________________________________________.

Our next step is to set up a time for you to talk with the principal investigator and review the study and expectations of agency administrators. Do you have a preferred email address and telephone number that the study’s principal investigator may use to contact you?”

Name: _______________________________________. Title: ____________________________________________.

Email: ________________________________________. Phone: _________________________________________.

If you have any questions please contact the study team at: XXXXXXX@pitt.edu or 412-###-####. Participation in this study is completely voluntary.

NHTSA Form Number 1460

Thank you.

NHTSA Form 1460