Form 1 Eligibility and Registration Form

AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture Database, Supporting Statement A

Attachment A: Eligibility and Registration Form

Ambulatory Surgery Center Survey on Patient Safety Culture Eligibility Form

We welcome your interest! To determine your organization's eligibility for participation in the Ambulatory Surgery Center Survey on Patient Safety Culture Database, we need to collect some information about you and your survey.

A field with an asterisk (*) before it is a required field.

* 1. Which of the following do you represent?

Ambulatory Surgery Center/Ambulatory Surgery Center Chain
Health System
An organization or vendor submitting data on behalf of an Ambulatory Surgery Center or Ambulatory Surgery Center chain
Other
Please specify:    

* 2. Will you have completed survey data collection and be able to submit your final electronic data file by [insert end date of data submission]?

Yes
No      

* 3. How many Ambulatory Surgery Centers will you be submitting for?

 

* 4. Have you used the Action Planning Tool for the AHRQ Surveys on Patient Safety Culture?

Yes
No      

* 5. Did you make any changes to the AHRQ Ambulatory Surgery Center Questionnaire?

Yes
No  

* If yes, please describe the changes (select all that apply)
	Added/Revised staff positions Added items Removed items Modified wording of item text Modified response options Reordered the items Other (please specify)

Ambulatory Surgery Center Survey on Patient Safety Culture Eligibility Form

If the registration information is incorrect, please click on the "Previous" button below and update your information.

Confirm your registration information

Organization Name:

Email:

First Name:

Last Name:

Address 1:

Address 2:

City:

State:

Zip:

Telephone:

Fax:

Ambulatory Surgery Center Survey on Patient Safety Culture Eligibility Form

Account registered.
An email message has been sent to [Email].
To ACTIVATE your account please follow the link emailed to you, Thank you!