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Information Request for Patient Safety Culture Assessment Services

3. Which survey services are you interested in? Select all that apply.
4. Will you need a Spanish version of the survey available? (Spanish surveys are not currently available for Home Care or EMS)
5. Select your hospital size by staffed beds: *This question is required.
6. Each location for your LTC, medical offices, pharmacies, home care, EMS and ASC will receive their own response reports.  What is the number of locations?
7. Preferred method of communication *This question is required.