Please complete the following questions to help us understand and meet your training needs.

Note:  The Stop the Bleed (STB) training course typically takes about 1 - 1.5 hours depending on class size and audience experience.

Question Title

* 1.  In what specific Michigan School Health Region is your school(s) located?  Click here to see a map of the regions.

Question Title

* 2.  County of requested STB training location (in Michigan):

Question Title

* 3.  How many persons do you estimate would take this proposed Stop the Bleed training course? 

Question Title

* 4.  Please describe the expected attendees who meet criteria to become Stop the Bleed Instructor:  Click here to view a list of professionals/disciplines eligible to be STB Instructors.  Check all that might attend.

Question Title

* 5.  Do you have a colleague(s) already trained as a Stop the Bleed Instructor who could assist in teaching this course?  If yes, please enter the number of available STB Instructors in the comment box at the end of this survey.

Question Title

* 6.  Do you have a specific space/room available to hold the STB Training Course?  (Screen, projector, and tables or other raised surfaces to use as hands-on demonstration stations for the training limbs and equipment are necessary.)

Question Title

* 7.  Location of the preferred training site (please list a specific address, building, and/or city):

Question Title

* 8.  Do you have STB training equipment (e.g., training tourniquets, limbs, gauze, etc.) available to use for this course?

Question Title

* 9.  When would you prefer to hold the Stop the Bleed Course?  Check as many months as you wish.  (If you have a specific meeting or event date that you want this course included in, please list it in the "other, please specify" box.)

Question Title

* 10.  Name of your local trauma center hospital (if known):

Question Title

* 11.  Does your school have or is your school offering:  (please check all that apply)

Question Title

* 12.  Primary Contact for this requested Stop the Bleed training course:

Question Title

* 13.  Please enter any comments, additional information, or questions below:  (For specific questions about the survey, please email ksklas@med.umich.edu)