Form 1 Setting Demographics Survey (Appendix A)

Appendix A – Setting-Level Demographics Survey

Form Approved
OMB No. xxxx-xxxx
Exp. Date xx/xx/20

Diagnostic Safety Capacity Building – TeamSTEPPS® Resource

Please complete the following information about your health care setting:

General Information About Your Health Care Setting

Health Care Setting Name
Mailing Address (City, State, Zip code)
Setting Facilitator or Champion (Name, Email, Telephone, Role, Title)
Total number of beds in health system
Total number of beds in health care setting (i.e., unit or practice) administering the Team Assessment Tool survey
Total number of staff in the health system	Physicians Physician Assistants	__________ __________
	Nurse Practitioners	___________
	Nurses	__________
	Medical Assistants	__________
	Pharmacists	___________
	Other Health Care Setting Staff	__________
	Other (specify)	__________
Total number of staff in the health care setting administering the Team Assessment Tool survey
Approximate Number of Patients Served by Health Care Setting	Weekly ________ Yearly ________

Information about Patient Safety and Quality Improvement Activities of the Setting

	Yes	No
Does your setting routinely conduct a patient safety culture survey?	Please specify which survey you use: ________________ Date of the last survey: _________________
Is your setting part of a larger healthcare system?	Please indicate which health system you are affiliated with: ___________________
Is your setting currently working on any other setting improvement strategies?
Does your setting have or use the services of a setting facilitator, educator or quality improvement champion?
Is your setting familiar with TeamSTEPPS® tools or resources?
Does your setting use TeamSTEPPS® tools or resources?

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)].  Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 60 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857.

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