Patient Safety

REGISTRATION FORM FOR USE OF SURVEYS AND RELATED TOOLS

Reminder: As per the existing copyright agreement, the Safety Attitudes and Safety Climate Questionnaires and related tools are for research purposes only and may not be sold or distributed commercially in any form. By downloading these materials, you agree to abide by these copyright guidelines.

Name:
Title:
Institution:
Address:
City/State/Zip:
Daytime Telephone:
E-mail Address:

Please list which surveys and/or tools you want to use:

1.

2.

3.

4.

5.

Please indicate below how you will use the survey, type of institution, number of institutions, and approximate number of individuals to be surveyed at each site:

Institution and Provider types
(i.e. Private Hospital, Trauma Nurses) Approximate number of Institutions Approximate number of Individuals

1.

2.

3.

4.

5.

Please indicate below for what purpose(s) you will use each survey by checking the appropriate box.

Research Quality Improvement Other (please describe)

1.

2.

3.

4.

5.

	Institution and Provider types (i.e. Private Hospital, Trauma Nurses)	Approximate number of Institutions	Approximate number of Individuals
1.
2.
3.
4.
5.

	Research	Quality Improvement	Other (please describe)
1.
2.
3.
4.
5.