Appendix A
Prior Experience Survey
Subject No. ________
PGY: I
II
III
IV
□Anesthesiology Resident
□PM&R
How many of the following procedures have you performed by yourself?
(successful and unsuccessful)
(i.e. >80% of the procedure)
1. Lumbar epidural
0
1 to 4
5 to 10
2. Thoracic epidural
0
1 to 4
5 to 10
3. Spinals
0
1 to 4
5 to 10
4. Peripheral Nerve Blocks
0
1 to 4
5 to 10
5. Visceral Plexus Blocks
0
1 to 4
5 to 10
6. Other Fluoroscopic Guided
0
1 to 4
5 to 10
Block
7. Other_________________
0
1 to 4
5 to 10
10 to 15
10 to 15
10 to 15
10 to 15
10 to 15
10 to 15
>15
>15
>15
>15
>15
>15
10 to 15
>15
How many of the following procedures have you assisted at?
(i.e. <80% of the procedure)
1. Lumbar epidural
0
1 to 4
2. Thoracic epidural
0
1 to 4
3. Spinals
0
1 to 4
4. Peripheral Nerve Blocks
0
1 to 4
5. Visceral Plexus Blocks
0
1 to 4
6. Other Fluoroscopic Guided
0
1 to 4
Block
7. Other_________________
0
1 to 4
5 to 10
5 to 10
5 to 10
5 to 10
5 to 10
5 to 10
10 to 15
10 to 15
10 to 15
10 to 15
10 to 15
10 to 15
>15
>15
>15
>15
>15
>15
5 to 10
10 to 15
>15
How many of the following procedures have you seen?
1. Lumbar epidural
0
2. Thoracic epidural
0
3. Spinals
0
4. Peripheral Nerve Blocks
0
5. Visceral Plexus Blocks
0
6. Other Fluoroscopic Guided
0
Block
7. Other_________________
0
1 to 4
1 to 4
1 to 4
1 to 4
1 to 4
1 to 4
5 to 10
5 to 10
5 to 10
5 to 10
5 to 10
5 to 10
10 to 15
10 to 15
10 to 15
10 to 15
10 to 15
10 to 15
>15
>15
>15
>15
>15
>15
1 to 4
5 to 10
10 to 15
>15
20