1. How many times per week are you called upon to perform a patient lift?
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2. How many times per week are you called upon to reposition or move a patient who is in a bed?
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3. How many times per week are you called upon to reposition or move a patient who is in a chair?
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4. Are all patients in your unit evaluated to determine:

• Their ability to move alone Y___ N___
• Their ability to move with assistance Y___ N___
• Their willingness to be cooperative when being moved Y___ N___

5. What percentage of patients on your unit are obese (20% above expected body weight)?
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6. Is there equipment available to assist you in lifting/moving patients? Y___ N___

7. If yes, have you been educated on the use of this equipment? Y___ N___

8. Have you received training on the topic of ergonomic injuries? Y___ N___

9. If yes, when did you receive this training?
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10. Are you able/willing to participate as a member of a lift team? Y___ N___

11. Would a lift team would be useful to you and the patients on your unit? Y___ N___

If no, please explain why a lift team would not be useful to you or to the patients.
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