POLST Implementation and Training
How widely is POLST implemented in your facility?	□ 0–25%      □ 26–50%      □ 51–75%      □76–99%      □ 100%
What is the total percent of the facility that POLST is planned to be implemented	□ 0–25%      □ 26–50%      □ 51–75%      □76–99%      □ 100%
How have you implemented POLST in your facility? (check all that apply)	□ Training seminar      □ Facility communications □ Provide professional education material □ Mandatory Curriculum        □ Web/Online training □ Provide patient/resident education material
What training materials are you using? (check all that apply)	□ POLST conference training material        □ Facility materials □ Web download material          □ Other:
Who is being trained? (check all that apply)	□All staff        □ Physician          □ Advanced Practice Nurse □ Social workers      □ Case managers      □ Clergy      □ Admissions □ Other:
Are there APRN providers, if yes: role in POLST	□ None      □ Education      □ Counseling patient/resident      □ Signing the POLST form
Permission to send relevant information via email related to POLST education?	□ Yes                    □No If yes, contact information: