Q01
Long Text
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Clinician Adverse Event Reporting Experience Survey
Measures clinicians' reporting behaviors, system usability, barriers to completeness, and safety culture around adverse event and near-miss reporting. Designed to surface actionable improvements for patient safety and quality leaders.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
26 questions · ~4 min
Q02
Multiple Choice
Does your role involve direct or indirect patient care, or oversight of patient safety or quality processes?
Q03
Long Text
Approximately how many adverse event or near-miss reports have you submitted in the past 6 months?
Q04
Long Text
Overall, how easy or difficult is it to file a report in your primary reporting system?
Q05
Long Text
How confident are you that your reports capture all the details needed for learning and follow-up?
Q06
Long Text
I feel safe reporting adverse events and near misses without fear of blame or repercussions.
Q07
Long Text
Please rank the following potential improvements from most to least impactful for your reporting experience.
Q08
Multiple Choice
What is your primary role?
Q09
Long Text
Thank you for completing this survey. Your responses are confidential and will be analyzed in aggregate to identify actionable improvements to reporting processes and patient safety. If you have questions, please contact [survey administrator].
Q10
Multiple Choice
When a near miss occurs in your work area, how often do you report it?
Q11
Multiple Choice
Typically, how long does it take you to complete one report?
Q12
Long Text
The required fields in the reporting system capture the information needed for learning and follow-up.
Q13
Multiple Choice
After submitting a report, how often do you receive feedback on the outcome or follow-up actions within 30 days?
Q14
Long Text
Based on your responses throughout this survey, what one change would most improve the ease or completeness of adverse event reporting in your practice?
Q15
Multiple Choice
What is your primary clinical setting?
Q16
Long Text
The steps required to submit a report are clear and easy to follow.
Q17
Multiple Choice
Which of the following factors most hinder your ability to report events or to report them completely? Select all that apply.
Q18
Multiple Choice
Have you received any training on adverse event or near-miss reporting in the past 12 months?
Q19
AI Interview
We'd like to explore your reporting experiences in a bit more depth. An AI moderator will ask you a couple of brief follow-up questions about your biggest challenges or suggestions for improving adverse event reporting.
Q20
Multiple Choice
How many years have you been in clinical practice?
Q21
Long Text
How easy or difficult is it to locate and access the reporting form or system?
Q22
Multiple Choice
Which of the following training formats or job aids would help you report more easily and completely? Select all that apply.
Q23
Multiple Choice
Which best describes your typical work schedule?
Q24
Long Text
How easy or difficult is it to select the correct event type and category?
Q25
Multiple Choice
In which region is your primary workplace located?
Q26
Long Text
How easy or difficult is it to enter the event narrative and supporting details?
What’s included
AI follow-ups
Adaptive probes on open-ended answers that pull out detail a static form would miss.
Attention checks
Built-in safeguards against rushed answers and low-quality respondents.
AI-drafted copy
Wording, ordering, and branching written by the AI — tuned to your research goal.
Auto report
Themes, quotes, and a plain-English summary write themselves once responses come in.
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.