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* 1. Which of the following best describes your job title?

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* 2. Which best describes the setting in which you work?

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* 3. If you work in a hospital, how many beds does it have?

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* 4. Has your facility conducted a formal assessment of your organization's readiness for ICD-10?

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* 5. If you answered "yes" to the previous question, which elements did your facility assess? (Check all that apply)

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* 6. Which best describes the upper management/executive level engagement of ICD-10 in your organization?

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* 7. Has your facility developed an ICD-10 implementation plan?

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* 8. Does your facility have an ICD-10 implementation team/committee?

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* 9. If you don’t currently have a steering/implementation committee in place how soon do you expect to have one up and running?

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* 10. If you answered yes to question 8, does someone from your CDI team attend ICD-10 steering/implementation committee meetings?

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* 11. Who serves on your steering/implementation committee? Check all that apply.

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* 12. If you answered yes to question 8, how frequently does your facility ICD-10 steering/implementation committee meet?

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* 13. How would you describe your HIM director’s role in ICD-10 implementation?

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