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Hello:
You are invited to participate in our survey [Project Description Here]. In this survey, approximately [Approximate Respondents] people will be asked to complete a survey that asks questions about [General Survey Process]. It will take approximately [Approximate Time] minutes to complete the questionnaire.

Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.

Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact [Name of Survey Researcher] at [Phone Number] or by email at the email address specified below.

Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.
 
 
 
Awareness:
Have you performed a gap analysis to determine the frequency, severity, and impact of the problem?
 
No activity to implement
 
Considered, but not implemented
 
Partially implemented in some or all areas
 
Fully implemented in some areas
 
Fully implemented throughout
 
 
 
Awareness:
Do you have, at a minimum, a yearly educational program targeted at the problem?
 
No activity to implement
 
Considered, but not implemented
 
Partially implemented in some or all areas
 
Fully implemented in some areas
 
Fully implemented throughout
 
 
 
Accountability:
Does your organization have a clear accountability chain from the frontline staff implementing the practice to leadership?
 
No activity to implement
 
Considered, but not implemented
 
Partially implemented in some or all areas
 
Fully implemented in some areas
 
Fully implemented throughout
 
 
 
Accountability:
Have you reported to senior leaders and boards (as needed) the gap and improvements targets?
 
No activity to implement
 
Considered, but not implemented
 
Partially implemented in some or all areas
 
Fully implemented in some areas
 
Fully implemented throughout
 
 
 
Ability:
Has your organization made available resources (allocated funds and dedicated staff time) towards implementation and training of this safe practice?
 
No activity to implement
 
Considered, but not implemented
 
Partially implemented in some or all areas
 
Fully implemented in some areas
 
Fully implemented throughout
 
 
 
Ability:
Has your organization assessed staff to match professional knowledge and skillset to the implementation requirements of this practice?
 
No activity to implement
 
Considered, but not implemented
 
Partially implemented in some or all areas
 
Fully implemented in some areas
 
Fully implemented throughout
 
 
 
Action:
Identification of Risks and Hazards: Governance boards and senior administrative leaders should be regularly and thoroughly briefed on the results of activities undertaken as defined by the Identification and Mitigation of Risks and Hazards safe practice.
 
No activity to implement
 
Considered, but not implemented
 
Partially implemented in some or all areas
 
Fully implemented in some areas
 
Fully implemented throughout
 
 
 
Action:
Culture Measurement, Feedback, and Intervention: Governance boards and senior administrative leaders should be regularly and thoroughly briefed on the results of culture measurement and performance improvement initiatives, addressed in the Culture Measurement, Feedback, and Intervention safe practice.
 
No activity to implement
 
Considered, but not implemented
 
Partially implemented in some or all areas
 
Fully implemented in some areas
 
Fully implemented throughout