Which department are you completing this survey for?

Name of the employee observed:

select

Pre-Brief completed?

Must be completed prior to patient being brought to OR

All team members present and engaged?

All team members present and engaged

No, Surgeon/Proceduralist [Non-Compliant Answer]

No, Anesthesiologist [Non-Compliant Answer]

No, OR RN [Non-Compliant Answer]

No, Surgical Tech [Non-Compliant Answer]