Surgical Coordination Feedback Survey
Share your feedback to help us enhance surgical team coordination and patient care.
Your Role in the Surgical Team
*
Please Select
Surgeon
Anesthesiologist
Scrub Nurse
Circulating Nurse
Surgical Assistant
Other
Date of Surgery Participated In
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Rate the following aspects of surgical coordination:
*
Rows
Excellent
Good
Average
Poor
Preoperative Communication
1
2
3
4
Intraoperative Communication
5
6
7
8
Postoperative Communication
9
10
11
12
Teamwork and Collaboration
13
14
15
16
Scheduling and Timeliness
17
18
19
20
Resource and Equipment Availability
21
22
23
24
How would you rate the overall effectiveness of surgical coordination for this case?
*
1
2
3
4
5
Were there any challenges or barriers to effective coordination during this surgery?
*
Yes
No
If yes, please describe the challenges or barriers encountered.
How satisfied are you with the communication between team members?
*
Not Satisfied
1
2
3
4
Very Satisfied
5
1 is Not Satisfied, 5 is Very Satisfied
How satisfied are you with the availability of necessary equipment and resources?
*
Not Satisfied
1
2
3
4
Very Satisfied
5
1 is Not Satisfied, 5 is Very Satisfied
What suggestions do you have to improve surgical coordination?
Any additional comments or feedback?
Would you like to be contacted for follow-up regarding your feedback?
Yes
No
If yes, please provide your email address.
example@example.com
Submit Feedback
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