Hospital Emergency Safety Survey
Help us evaluate and improve our hospital's emergency safety procedures by sharing your experiences and observations.
Your Name
*
First Name
Last Name
Your Department or Unit
*
Please Select
Emergency Department
Surgery
Intensive Care Unit (ICU)
Pediatrics
Radiology
Laboratory
Administration
Other
Your Role
*
Doctor
Nurse
Support Staff
Administrator
Other
How confident are you in the hospital's overall emergency preparedness?
*
1
2
3
4
5
Please rate the following aspects of emergency safety in your department.
*
Rows
Excellent
Good
Average
Poor
Availability of emergency equipment
1
2
3
4
Staff training on emergency protocols
5
6
7
8
Clarity of evacuation procedures
9
10
11
12
Communication during emergencies
13
14
15
16
Response time to emergencies
17
18
19
20
Have you participated in an emergency drill in the past 12 months?
*
Yes
No
If yes, how effective was the emergency drill?
Not effective
1
2
3
4
Highly effective
5
1 is Not effective, 5 is Highly effective
Do you know how to report an emergency or safety incident?
*
Yes
No
Not sure
What do you see as the greatest emergency safety risk in your area?
Please share any suggestions you have for improving emergency safety in the hospital.
Would you like to be contacted for follow-up or further discussion?
Yes
No
Your Email Address (if you wish to be contacted)
example@example.com
Submit Survey
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