Date of MIST Delivery	Time of MIST Delivery:	Dose of Surfactant O. First      O. Second
Ventilation support when MIST decided	○ CPAP ○ PEEP______ ○ FIO2______	○ NIPPV ○ PEEP______ PIP________ ○ FIO2_______
MIST PROCEDURE
Atropine	○Yes	○No ○If No Why: _______________
Fentanyl Given	○Yes ○Dose:_____________ ○Number of doses:	○No ○If No Why: _______________
Sucrose	○yes	○No
Bradycardia (<100 bpm)	○Yes	○No
Apnea	○Yes	○No
Desaturation (SpO2 < 85%)	○Yes	○No
Need for PPV during procedure	○yes	○No
Need to Intubate during procedure	○yes	○No
Amount of Surfactant Obtained on Gastric Aspiration	○None ○Minimal ○Moderate to Large Volume ○Not Done
Able to deliver full dose of surfactant	○Yes	○NO ○If no explain:
Multiple Attempts Needed To deliver Surfactant By MIST	○Yes ○Number of Attempts-__	○No
PROCEDURE PREFORMER
	Attempt 1	Attempt 2	Attempt 3
Profession:	RT- Fellow, Resident, NP, Staff	RT- Fellow, Resident, NP, Staff	RT- Fellow, Resident, NP, Staff
Laryngoscope:	O. Direct          O. Video	O. Direct          O. Video	O. Direct          O. Video
Type of Catheter:
Ease of use (Laryngoscope)	○Very easy ○Relatively Easy ○Neither Easy nor Difficult ○Somewhat difficult ○Very Difficult	○Very easy ○Relatively Easy ○Neither Easy nor Difficult ○Somewhat difficult ○Very Difficult	○Very easy ○Relatively Easy ○Neither Easy nor Difficult ○Somewhat difficult ○Very Difficult
Ease of Use of Catheter	○Very easy ○Relatively Easy ○Neither Easy nor Difficult ○Somewhat difficult ○Very Difficult	○Very easy ○Relatively Easy ○Neither Easy nor Difficult ○Somewhat difficult ○Very Difficult	○Very easy ○Relatively Easy ○Neither Easy nor Difficult ○Somewhat difficult ○Very Difficult
Additional Comments or Complications: