March 27th, 2022 
370 Part 4: Measurement Concepts
CASE EXHIBIT 15.11 AHRQ Hospital Questionnaire (continued)
SECTION H: Background InformationThis information will help in the analysis of the survey results. Mark ONE answer by filling in the circle.
1. How long have you worked in this hospital?
a . Less than 1 year d. 11 to 15 years b. 1 to 5 years e. 16 to 20 years c. 6 to 10 years f. 21 years or more
2. How long have you worked in your current hospital work area/unit?
a . Less than 1 year d. 11 to 15 years b. 1 to 5 years e. 16 to 20 years c. 6 to 10 years f. 21 years or more
3. Typically, how many hours per week do you work in this hospital?
a. Less than 20 hours per week d. 60 to 79 hours per weekb. 20 to 39 hours per week e. 80 to 99 hours per weekc. 40 to 59 hours per week f. 100 hours per week or more
4. What is your staff position in this hospital? Mark ONE answer that best describes your staff position.
a. Registered Nurse h. Dietician b. Physician Assistant/Nurse Practitioner i. Unit Assistant/Clerk/Secretary c. LVN/LPN j. Respiratory Therapistd. Patient Care Assistant/Hospital Aide/Care Partner k. Physical, Occupational, or Speech Therapist
e. Attending/Staff Physician l. Technician (e.g., EKG, Lab, Radiology)f. Resident Physician/Physician in Training m. Administration/Management
g. Pharmacist n. Other, please specify:
5. In your staff position, do you typically have direct interaction or contact with patients?
a. YES, I typically have direct interaction or contact with patients.b. NO, I typically do NOT have direct interaction or contact with patients.
6. How long have you worked in your current specialty or profession?
a . Less than 1 year d. 11 to 15 years b. 1 to 5 years e. 16 to 20 years c. 6 to 10 years f. 21 years or more
SECTION I: Your CommentsPlease feel free to write any comments about patient safety, error, or event reporting in your hospital.
THANK YOU FOR COMPLETING THIS SURVEY.
Source: Agency for Healthcare Research and Quality, “Hospital Survey on Patient Safety Culture,” http://www.ahrq.gov/qual/hospculture/.
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