Healthcare Gap Analysis & Risk Assessment Questionnaire
Help us identify gaps and assess risks in your healthcare services by completing this structured questionnaire.
Respondent Information
Please provide your contact and organizational details.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Organization Name
*
Role/Position
*
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Current Healthcare Services Assessment
*
Rows
Service Availability
Service Quality
Staff Adequacy
Primary Care
1
2
3
Emergency Services
4
5
6
Specialist Services
7
8
9
Mental Health Services
10
11
12
Preventive Care
13
14
15
Please rate the overall performance of your healthcare facility in the following areas:
*
Rows
Poor
Fair
Good
Excellent
Patient Safety
16
17
18
19
Infection Control
20
21
22
23
Patient Satisfaction
24
25
26
27
Data Management
28
29
30
31
Which of the following gaps are present in your current healthcare services? (Select all that apply)
*
Insufficient staffing
Limited access to equipment
Inadequate training
Lack of patient education
Other (please specify)
Please indicate the level of risk for the following factors in your organization:
*
Rows
Low Risk
Moderate Risk
High Risk
Patient Data Breach
32
33
34
Staff Shortages
35
36
37
Medication Errors
38
39
40
Facility Safety Issues
41
42
43
Which area do you consider the highest priority for improvement?
*
Staffing
Equipment/Resources
Training/Education
Patient Processes
Other (please specify)
How would you rate your organization's preparedness for emergency situations?
*
1
2
3
4
5
Please provide any additional comments or details regarding healthcare gaps or risks in your organization.
Submit Assessment
Should be Empty: