Clinic Safety Readiness Survey Form
Evaluate your clinic's safety preparedness with this concise survey. Please answer each item to help assess readiness and identify potential areas for improvement.
Which best describes your role at the clinic?
*
Please Select
Clinic Manager
Nurse
Physician
Administrative Staff
Other
How confident are you in your clinic's emergency response protocols?
*
Not confident
1
2
3
4
Extremely confident
5
1 is Not confident, 5 is Extremely confident
Which of the following safety measures are currently in place at your clinic? (Select all that apply)
*
Fire extinguishers accessible
First aid kits stocked
Regular safety drills conducted
Emergency exits clearly marked
Staff trained in basic life support
Other
Rate the overall cleanliness and sanitation of the clinic.
*
1
2
3
4
5
How often is safety equipment (e.g., fire extinguishers, first aid kits) inspected?
*
Monthly
Quarterly
Annually
Not sure
Please indicate the level of staff participation in recent safety training sessions.
*
None
1
2
3
4
All staff
5
1 is None, 5 is All staff
Does the clinic have a designated safety officer or coordinator?
*
Yes
No
Not sure
Please rate the clarity of safety signage and instructions throughout the clinic.
*
1
2
3
4
5
Are there any areas of safety concern you would like to highlight?
How would you describe the clinic's overall safety readiness?
*
Excellent
Good
Fair
Needs improvement
Submit Survey
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