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Medical Office Survey on Patient Safety Culture Data Submission
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: After completing the form users will receive an email including login information to activate the account.
Definition of a Medical Office
- A medical office is an outpatient facility in a specific location.
- Each medical office located in a building containing multiple medical offices is considered a separate medical office.
- Providers in a single medical office should share administrative and clinical support staff.
To submit data to the database:
- Medical offices must be located in the United States or in a U.S. territory.
- Each medical office must have at least five completed surveys to receive an individual feedback report. Medical offices with 3 to 4 respondents will be included in the database.
- The survey must have been administered in its entirety without significant modifications or deletions:
- No changes to any of the survey item text and response options.
- No reordering of survey items.
- Questions added only at the end of the survey after Section G, before the demographic questions in Section H.
What You Will Need for Submission
- Data Use Agreement: Each medical office is required to sign a Data Use Agreement (DUA) and fax it to 1-888-852-8277.
- Medical Office Data Use Agreement (PDF, 188 KB, PDF HELP)
- Medical Office Questionnaire(s) Administered: Users will need to upload a copy of the actual questionnaire(s) administered. If you used a copy of the Spanish questionnaire, please upload this questionnaire as well. We will review the submitted questionnaire(s) and users will receive an approved/not approved email within 3 business days.
NOTE: Your questionnaire will not be approved if
- You made changes to any of the questionnaire item text and/or response options.
- You reordered questionnaire items A1−G2.
- You added new questions between items A1 and G2 and did not add new questions at the end of the questionnaire after Section G, before the demographic questions in Section H.
- Medical Office Site Information: Users can upload medical office site information in one of two ways, one at a time on the Data Submission Web site or all at once in an Excel spreadsheet.
- Medical Office Site-Level Specifications (PDF, 205 KB, PDF HELP)
- Sample Medical Office Site Information Data File (XLSX, 23 KB)
- Medical Office Data: Users will need to upload their Medical Office survey data, conforming to the Medical Office Data Specifications.
- Medical Office Survey Data Specifications (PDF, 383 KB, PDF HELP)
- Sample Medical Office Survey Data File (XLSX, 18 KB)
Survey Form and User's Guide
- Medical Office Survey—English (PDF, 172 KB; MS Word, 188 KB)
- Medical Office Survey—Spanish (PDF, 232 KB; MS Word, 213 KB)
- Medical Office Survey User's Guide (PDF, 1.2 MB)
For technical assistance on data submission, email DatabasesOnSafetyCulture@westat.com or call 1-888-324-9790.