To support a culture of patient safety and quality improvement, the Indiana Hospital Association (IHA) offers the Agency for Healthcare Research and Quality (AHRQ) Surveys on Patient Safety Culture free to all IHA members. Please fill out the information below to start the survey set-up process.

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* 1. Medical Office Name:

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* 2. Medical Office Address:

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* 3. Who is the campaign administrator?

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* 4. Campaign Name
Recommendation: Office Name Year i.e. Indiana Medical Office 2016

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* 5. Denominator 
Number of staff asked to complete the survey

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* 6. Please select the date you want to open and close your survey campaign:

Open Campaign Date
Close Campaign Date

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* 7. Do you want to submit your survey data to AHRQ as part of the National Comparative Database? 
AHRQ will not receive any written in comments.

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