Surgical Safety Checklist Printable PDF Survey Template

Looking for the paper-based survey data collection solution for your organization? Take a look at this surgical safety checklist printable pdf survey template for your upcoming research project.

Our templates come with well-designed questions that can be machine-read to recognize the checkmarks using optical mark recognition (OMR) technologies. Open text areas recognized with handwriting recognition (HWR) technologies allowing you to write handwritten text and automatically convert to a digitized format.

Questions in this survey: 28, Language: English

Preview Template

Loading preview...


Get this paper survey Template

Like this template? Use or customize this template to suit your needs.



List of questions in this template

  1. **Surgical Safety Checklist Printable PDF Survey** (by the World Health Organization)
  2. Before induction of anaesthesia
  3. (with at least nurse and anaesthetist)
  4. Has the patient confirmed his/her identity, site, procedure, and consent?
  5. Is the site marked?
  6. Is the anaesthesia machine and medication check complete?
  7. Is the pulse oximeter on the patient and functioning?
  8. **Does the patient have a: **
  9. Known alergy
  10. Difficult airway or aspiration risk?
  11. Risk of >500ml blood loss (7ml/kg in children)?
  12. Question 23
  13. Before skin incision
  14. (with nurse, anaesthetist and surgeon)
  15. Confirm all team members have introduced themselves by name and role
  16. Confirm the patient’s name, procedure, and where the incision will be made.
  17. Has antibiotic prophylaxis been given within the last 60 minutes?
  18. Anticipated Critical Events
  19. To Surgeon:
  20. To Anaesthetist:
  21. To Nursing Team:
  22. Is essential imaging displayed?
  23. Is essential imaging displayed?
  24. Before patient leaves operating room
  25. (with nurse, anaesthetist and surgeon)
  26. Nurse Verbally Confirms:
  27. To Surgeon, Anaesthetist and Nurse:
  28. This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged. The checklist is based on the World Health Organization Patient Survey (Revised 1 / 2009).


Get Started with PaperSurvey.io Software

Get Started

Start your 14-day free trial now, no credit card required.