Quick Reference Phone Number
Virtual Command Center: Veronica Johnson 410-502-2133
Surveyor Team

Surveyor Name:

Scribe Name:

Staff Interviewed (include name, role and badge #):

Survey Area (Note when location changes):

MRN# of Charts Reviewed:

Tracer Information

Verbatim Notes:

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Summary of Major Concerns/ Issues:

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Positive/ Compliments to Individuals:

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Additional Notes:

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Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.