Incident Survey Questionnaire

Please fill out the survey below.

Identification and response

I know what an incident is
I know what a safety event is
I would be able to identify an incident if I saw one
I would know how to respond appropriately if I saw an incident occur
I report all incidents even though they are small
I am strongly committed to the prevention of adverse events
As long as no‐one gets hurt, I do not report incidents
I do not report incidents because I am not sure if I am allowed to report more than 1
My manager/supervisor treats incidents as learning opportunities
I know how to check RL system for feedback once my incident has been closed


I am familiar with the procedures for reporting an incident on RL
It does not take much time to fill an incident report on RL
I would feel quite comfortable reporting an incident in which I made an error or omission
In my unit there is no blame or stigma attached to reporting an incident. If you disagree or strongly disagree, can you help us better understand why below?
My manager/supervisor allocates sufficient priority to incident reporting
The more incidents you report the better the reporting culture
I am perceived with negativity from my colleagues if I report many incidents
In my organization people tend to cover up mistakes*
My manager encourages me to report an incident even if it means our unit could be questioned about our practices
I prefer anonymous reporting (Please provide a reason below if agreed or strongly agreed)

What is a good reporting culture in your opinion? Please state the answer below.


My organization accepts that people make mistakes and puts the focus of incident investigations on system improvement
I have used incidents that I have reported as lessons learnt
Incident investigations usually identify the causal factors that led to the incident
Incidents in my organization are investigated impartially and objectively

Using a survey of incident reporting and learning practices to improve organizational learning at a cancer care center, David L Cooke, Peter B Dunscombe, and Robert C Lee