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888-324-9790

DatabasesOnSafetyCulture@westat.com

OMB Control Number: 0935-0195
Expiration Date: 3/31/2028

Nursing Home Survey on Patient Safety Culture Eligibility Form

We welcome your interest! To determine your organization's eligibility for participation in the Nursing Home Survey on Patient Safety Culture Database, we need to collect some information about you and your survey.

A field with an asterisk (*) before it is a required field.

* 1. Which of the following do you represent?

Nursing home/Nursing home system/chain
Quality Improvement Organization (QIO)
An organization or vendor submitting data on behalf of a nursing home or nursing home system/chain
Another type of healthcare organization (please specify)

Please specify:

* 2. Will you have completed survey data collection and be able to submit your final electronic data file
by September 18, 2026?

Yes
No

* 3. How many nursing homes will you be submitting for?

* 4. Have you used the Action Planning Tool for the AHRQ Surveys on Patient Safety Culture^®?

Yes
No

* 5. Did you make any changes to the AHRQ Nursing Home Questionnaire?

Yes
No