Company Name

E-mail

1. We have an arts related program. yes no does not apply

2. We would like to have an arts related program. yes no does not apply

3. We have original works of art in our facility. yes no does not apply

4. We have paid artists in our facility. yes no does not apply

4a. Average hourly wage (Check one or both): $7.50 or below $7.51 or above

5. We would like to employ artists in our facility yes no does not apply

5a. If not, is this due to financial constraints? yes no

6. We would like to employ artists in the future. yes no does not apply

7. We would like our patients to participate in creative activities. yes no does not apply

8. We have volunteer artists at this time. yes no does not apply

9. We recognize the value of art in a healing environment. yes no does not apply

Please check any specific skills or knowledge you would require of an artist hired to work in your facility:

Arts technique/skills hospital etiquette communication skills medical knowledge

Group leadership skills confidentiality child management skills fire safety

150-300 hours of bedside/clinical experience 300 or more hours of bedside/clinical experience

Additional skills, knowledge or experience required

Additional Comments