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CRNA Leadership Application Form
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Research
CRNA Leadership Application Form
Are you currently a Chief CRNA and/or Leader at your organization? (E.g., Employer of CRNAs, Military Specialty Leader of CRNAs, Anesthesia Department Chair/Head, Practice or Group Owner/Partner)
Yes
No
First and Last Name
Phone Number
Email Address
Current Title/Position
Name of your organization/facility
What is your gender?
Male
Female
Other
Prefer not to answer
Are you of Hispanic, Latino or Spanish origin?
Yes
No
Please indicate your race.
American Indian or Alaska Native
Middle Eastern/North African
Black or African American
Asian
Native Hawaiian or other Pacific Islander
White/Caucasian
Prefer not to respond
Other...
Which state or territory do you practice in?
In what type of geographic areas do you work as a CRNA? Select all that apply.
Rural
Mid-size area/small town (i.e., mostly rural, not urban)
Urban
Don't know
At the end of 2021, how long have you been practicing as a CRNA? (Clinical Anesthesia, Nurse-Anesthesia Related Administration, Education, or Research)
1 year of less
2-5 years
6-10 years
11-20 years
21-30 years
31 or more
At the end of 2021, how long have you been a Chief CRNA/Leader in your organization?
1 year of less
2-5 years
6-10 years
11-20 years
21-30 years
31 or more
What is your highest degree obtained?
Bachelor's or Bachelor's of Science in Nursing Degree
Master's Degree
Practice Doctorate (DNP, DNAP)
Juris Doctorate (JD)
Research Doctorate (PhD, EdD, DNSc)
What is your primary position?
Research
Practice
Education
Management/Administration
Other...
What is your primary practice setting (i.e., the location where you spent the most time practicing in 2021?)
Hospital inpatient and outpatient facility
Free-standing ambulatory surgery center
Physician's office
Dentist office
Pain management clinic
Gastroenterology Clinic
Fertility Clinic
Other...
What is your primary employment arrangement?
Employee of a hospital
Employee of a group
Independent contractor
Owner/operator
Military/Government/VA
University/Academic Setting
Other...
How would you describe the delivery model in your primary practice setting?
Anesthesiologist directly involved in the provision of anesthesia with a small number of CRNAs or Anesthesiologist Assistants (AAs) (e.g., medical direction of 1 to 4 CRNAs or AAs concurrently)
Anesthesiologist directly overseeing the provision of anesthesia care and supervising a larger number of CRNAs (e.g., medical supervision of 5 or more CRNAs concurrently)
CRNA practicing independently with anesthesiologist involvement as needed
CRNA practicing independently with no anesthesiologist involvement
Other...
How many CRNAs practice/work in your primary practice setting?
How many CRNAs do you lead/manage/supervise?
How many Student Registered Nurse Anesthetists (SRNAs) practice/work in your primary practice setting?
How many Physician Anesthesiologists practice/work in your primary practice setting?
How many Anesthesiologist Assistants (AAs) practice/work in your primary practice setting?
Can you refer me to other Chief CRNAs/employers that I can interview who would be interested?
Yes
No
If yes, please provide their contact information below (name, email, and/or phone number).
Would you be interested in being contacted to participate in any follow-up and/or future research studies?
Yes
No
Submit
Current Evidence
Evaluation and Research Advisory Committee
Research Studies
Longitudinal Assessment Research Study
CRNA Leadership Interview Application
