Physician Skills Survey Template – From Scratch

The following has all of the text for you to create your own survey using whatever survey tool you like.

Note that, if you create your own, you may have to modify the output to use the other modules we are deploying in the coming days–to avoid that, use our Google Forms template.

Template text below:

[Insert Your Institution Name] Attending Skills Survey

The COVID-19 crisis poses a massive human resources challenge. This survey is designed to help our institution manage staffing needs based on physician skillsets in the event redeployment is needed.

Thank you for your dedication and willingness to help in these challenging times.

Last Name


First Name


Your Primary Clinical Department (select one)

  • Anesthesiology
  • Dermatology
  • Emergency Medicine
  • Family Medicine
  • General Surgery
  • Internal Medicine
  • Medicine – Pediatrics
  • Neurology
  • Neurosurgery
  • Nuclear Medicine
  • Obstetrics-Gynecology
  • Ophthalmology
  • Orthopaedic Surgery
  • Otolaryngology
  • Pathology
  • Pediatrics
  • Plastic Surgery
  • Physical Medicine & Rehabilitation
  • Psychiatry
  • Radiation Oncology
  • Radiology
  • Urology
  • Other… Please Specify ________________________________

For the following skill sets or work examples, please check the box indicating your level of comfort:

SKILLED: This is a part of your current job, and you are very comfortable performing these actions. (e.g. anesthesiologist = intubation, critical care attending = ICU management).

NEED TRAINING: You have done this type of work before, but you would need some training or supervision to feel comfortable; or, this is not something you do every day but that you are willing to perform if necessary.

NOT COMFORTABLE: These are skills or tasks that you are either entirely unfamiliar with (and do not think you could learn in a safe way within 1-2 weeks), or that you would NOT be willing to do for any reason.

Care of non-critical care COVID medicine patients
General inpatient adult care
General inpatient pediatric care
Non-critical emergency department care (adults)
Non-critical emergency department care (pediatrics)
Ambulatory care
Critical care/Vent management
Obstetric care
Bedside procedures (central lines, arterial lines)
Triage/Screening for COVID
Palliative care

Would you be willing to redeploy to non-clinical responsibilities if needed; e.g. patient transportation, room turnover, supply distribution?

◯ Yes        ◯ No