Sample Likert Scale Template

(Company Name)

The following questions ask you about your current work environment. Circle the number that most closely
indicates the extent to which the item is present in your current job:

Please specify by checking the Respondent Type that most closely matches your position
Registered Nurse Dietary personnel
Physician Respiratory Therapist
LPN Physical Therapist
Nursing Assistant Other
Unit Clerk

Circle the correct numeric response to each question

Survey Scale: 1=Strongly Disagree
2=Disagree 3=Neutral 4=Agree
# Question 5=Strongly Agree

I have easy access to the supplies and equipment I need to

1
do my work on this unit. 1 2 3 4 5

2 The support services to this unit respond in a timely way. 1 2 3 4 5

I can discuss challenging issues with care team members on

3
this unit. 1 2 3 4 5

4 My ideas really seem to count on this unit. 1 2 3 4 5

5 I speak up if I have a patient safety concern. 1 2 3 4 5

Care team members on this unit feel free to question the

6
decisions or actions of those with more authority. 1 2 3 4 5

Important patient care information is exchanged during shift

7
changes. 1 2 3 4 5

If I have an idea about how to make things better on this unit,

8
the manager and other staff are willing to try it. 1 2 3 4 5

Care professionals communicate complete patient

9
information during hand-offs. 1 2 3 4 5

Essential patient care equipment is in good working condition

10
on this unit. 1 2 3 4 5
 Circle the correct numeric response to each question
Survey Scale: 1=Strongly Disagree
2=Disagree 3=Neutral 4=Agree
# Question 5=Strongly Agree

PLEASE COMPLETE SURVEY BY: (enter due date)

RETURN TO: (enter location/person)
THANK YOU!
 Overall Mean
SUM 0 0 0 0 0
MEAN #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Cat Respondent Type SUM MEAN Q_1 Q_2 Q_3 Q_4 Q_5
1 0 #DIV/0!
2 0 #DIV/0!
3 0 #DIV/0!
4 0 #DIV/0!
5 0 #DIV/0!
6 0 #DIV/0!
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10 0 #DIV/0!
11 0 #DIV/0!
12 0 #DIV/0!
13 0 #DIV/0!
14 0 #DIV/0!
15 0 #DIV/0!
16 0 #DIV/0!
17 0 #DIV/0!
18 0 #DIV/0!
19 0 #DIV/0!
20 0 #DIV/0!
21 0 #DIV/0!
22 0 #DIV/0!
23 0 #DIV/0!
24 0 #DIV/0!
25 0 #DIV/0!
26 0 #DIV/0!
27 0 #DIV/0!
28 0 #DIV/0!
29 0 #DIV/0!
30 0 #DIV/0!
31 0 #DIV/0!
32 0 #DIV/0!
33 0 #DIV/0!
34 0 #DIV/0!
35 0 #DIV/0!
36 0 #DIV/0!
37 0 #DIV/0!
38 0 #DIV/0!
39 0 #DIV/0!
40 0 #DIV/0!
41 0 #DIV/0!
42 0 #DIV/0!
43 0 #DIV/0!
44 0 #DIV/0!
45 0 #DIV/0!
46 0 #DIV/0!
47 0 #DIV/0!
48 0 #DIV/0!
49 0 #DIV/0!
50 0 #DIV/0!
51 0 #DIV/0!
52 0 #DIV/0!
53 0 #DIV/0!
54 0 #DIV/0!
55 0 #DIV/0!
56 0 #DIV/0!
57 0 #DIV/0!
58 0 #DIV/0!
59 0 #DIV/0!
60 0 #DIV/0!
61 0 #DIV/0!
62 0 #DIV/0!
63 0 #DIV/0!
64 0 #DIV/0!
65 0 #DIV/0!
66 0 #DIV/0!
67 0 #DIV/0!
68 0 #DIV/0!
69 0 #DIV/0!
70 0 #DIV/0!
71 0 #DIV/0!
72 0 #DIV/0!
73 0 #DIV/0!
74 0 #DIV/0!
75 0 #DIV/0!
76 0 #DIV/0!
77 0 #DIV/0!
78 0 #DIV/0!
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80 0 #DIV/0!
81 0 #DIV/0!
82 0 #DIV/0!
83 0 #DIV/0!
84 0 #DIV/0!
85 0 #DIV/0!
86 0 #DIV/0!
87 0 #DIV/0!
88 0 #DIV/0!
 89 0 #DIV/0!
90 0 #DIV/0!
91 0 #DIV/0!
92 0 #DIV/0!
93 0 #DIV/0!
94 0 #DIV/0!
95 0 #DIV/0!
96 0 #DIV/0!
97 0 #DIV/0!
98 0 #DIV/0!
99 0 #DIV/0!
100 0 #DIV/0!
101 0 #DIV/0!
102 0 #DIV/0!
103 0 #DIV/0!
104 0 #DIV/0!
105 0 #DIV/0!
106 0 #DIV/0!
107 0 #DIV/0!
108 0 #DIV/0!
109 0 #DIV/0!
110 0 #DIV/0!
111 0 #DIV/0!
112 0 #DIV/0!
113 0 #DIV/0!
114 0 #DIV/0!
115 0 #DIV/0!
116 0 #DIV/0!
117 0 #DIV/0!
118 0 #DIV/0!
119 0 #DIV/0!
120 0 #DIV/0!
121 0 #DIV/0!
122 0 #DIV/0!
123 0 #DIV/0!
124 0 #DIV/0!
125 0 #DIV/0!
126 0 #DIV/0!
127 0 #DIV/0!
128 0 #DIV/0!
129 0 #DIV/0!
130 0 #DIV/0!
131 0 #DIV/0!
132 0 #DIV/0!
133 0 #DIV/0!
134 0 #DIV/0!
135 0 #DIV/0!
136 0 #DIV/0!
137 0 #DIV/0!
138 0 #DIV/0!
139 0 #DIV/0!
140 0 #DIV/0!
141 0 #DIV/0!
142 0 #DIV/0!
143 0 #DIV/0!
144 0 #DIV/0!
145 0 #DIV/0!
146 0 #DIV/0!
147 0 #DIV/0!
148 0 #DIV/0!
149 0 #DIV/0!
150 0 #DIV/0!
151 0 #DIV/0!
152 0 #DIV/0!
153 0 #DIV/0!
154 0 #DIV/0!
155 0 #DIV/0!
156 0 #DIV/0!
157 0 #DIV/0!
158 0 #DIV/0!
159 0 #DIV/0!
160 0 #DIV/0!
161 0 #DIV/0!
162 0 #DIV/0!
163 0 #DIV/0!
164 0 #DIV/0!
165 0 #DIV/0!
166 0 #DIV/0!
167 0 #DIV/0!
168 0 #DIV/0!
169 0 #DIV/0!
170 0 #DIV/0!
171 0 #DIV/0!
172 0 #DIV/0!
173 0 #DIV/0!
174 0 #DIV/0!
175 0 #DIV/0!
176 0 #DIV/0!
177 0 #DIV/0!
178 0 #DIV/0!
179 0 #DIV/0!
180 0 #DIV/0!
181 0 #DIV/0!
182 0 #DIV/0!
183 0 #DIV/0!
184 0 #DIV/0!
185 0 #DIV/0!
186 0 #DIV/0!
187 0 #DIV/0!
188 0 #DIV/0!
189 0 #DIV/0!
190 0 #DIV/0!
191 0 #DIV/0!
192 0 #DIV/0!
193 0 #DIV/0!
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195 0 #DIV/0!
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198 0 #DIV/0!
199 0 #DIV/0!
200 0 #DIV/0!
 0 0 0 0 0
#DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Q_6 Q_7 Q_8 Q_9 Q_10
Total Number of Surveys 0
 Healthcare Team Vitality Instrument (HTVI)
(Company Name)
Survey Scale: 1=Strongly Disagree 2=Disagree 3=Neutral 4=Agree 5=Strongly Agree
Course Evaluation Survey # 1's #2's #3's #4's #5's n MEAN MODE SEM

1. I have easy access to the supplies and equipment I need

0 0.00 0 0.0
to do my work on this unit.

2. The support services to this unit respond in a timely way. 0 0.00 0 0.0

3. I can discuss challenging issues with care team members

0 0.00 0 0.0
on this unit.

4. My ideas really seem to count on this unit. 0 0.00 0 0.0

5. I speak up if I have a patient safety concern. 0 0.00 0 0.0

6. Care team members on this unit feel free to question the

0 0.00 0 0.0
decisions or actions of those with more authority.

7. Important patient care information is exchanged during

0 0.00 0 0.0
shift changes.

8. If I have an idea about how to make things better on this

0 0.00 0 0.0
unit, the manager and other staff are willing to try it.

9. Care professionals communicate complete patient

0 0.00 0 0.0
information during hand-offs.

10. Essential patient care equipment is in good working

0 0.00 0 0.0
condition on this unit.

Respondent Type Counts

Registered Nurse0

Physician0

LPN0

Nursing Assistant 0

Unit Clerk 0

Dietary personnel 0
 Physician0

LPN0
Survey Scale: 1=Strongly Disagree 2=Disagree 3=Neutral 4=Agree 5=Strongly Agree
Course Nursing
Evaluation Survey
Assistant 0 # 1's #2's #3's #4's #5's n MEAN MODE SEM

Unit Clerk 0

Dietary personnel 0

Respiratory Therapist 0

Physical Therapist 0

Other0

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

 Healthcare Team Vitality Instrument (HTVI)
(Company Name)

1. I have easy access to the supplies and equipment I need to do my work on this unit.

0.8

0.6

0.4

0.2

0
#0
1's 0
#2's 0
#3's 0
#4's 0
#5's

2. The support services to this unit respond in a timely way.

0.8

0.6

0.4

0.2

0
#0
1's 0
#2's 0
#3's 0
#4's 0
#5's

3. I can discuss challenging issues with care team members on this unit.

0.8

0.6

0.4

0.2

0
#0
1's 0
#2's 0
#3's 0
#4's 0
#5's

4. My ideas really seem to count on this unit.

1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
#0
1's 0
#2's 0
#3's 0
#4's 0
#5's
0.6
0.5
0.4
0.3
0.2
0.1
0
#0
1's 0
#2's 0
#3's 0
#4's 0
#5's
 5. I speak up if I have a patient safety concern.

1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
#0
1's 0
#2's 0
#3's 0
#4's 0
#5's

6. Care team members on this unit feel free to question the decisions or actions of those with more authority.

1
0.8
0.6
0.4
0.2
0
# 01's 0
#2's 0
#3's 0
#4's 0
#5's

7. Important patient care information is exchanged during shift changes.

1
0.8
0.6
0.4
0.2
0
#0
1's 0
#2's 0
#3's 0
#4's 0
#5's

8. If I have an idea about how to make things better on this unit, the manager and other staff are willing to try it.

1
0.8
0.6
0.4
0.2
0
# 01's 0
#2's 0
#3's 0
#4's 0
#5's
 9. Care professionals communicate complete patient information during hand-offs.

1
0.8
0.6
0.4
0.2
0
#0
1's 0
#2's 0
#3's 0
#4's 0
#5's

10. Essential patient care equipment is in good working condition on this unit.

1
0.8
0.6
0.4
0.2
0
#0
1's 0
#2's 0
#3's 0
#4's 0
#5's
 Healthcare Team Vitality Instrument (HTVI)
(Company Name)

1. I have easy access to the supplies and equipment I need to do my work on this unit. 2. The support services to this unit respond in a timely way.

1 1
0.9 1 0.9 2
0.8 0.8
0.7 0.7
0.6 0.6
0.5 0.5
0.4 0.4
0.3 0.3
0.2 0.2
0.1 0.1
0 0

# 01's 0
#2's 0
#3's 0
#4's 0
#5's #0
1's 0
#2's 0
#3's 0
#4's 0
#5's

3. I can discuss challenging issues with care team members on this unit. 4. My ideas really seem to count on this unit.

1 1
0.9 0.9
0.8
0.7 3 0.8
0.7
4
0.6
0.6
0.5
0.5
0.4
0.4
0.3
0.3
0.2
0.2
0.1
0.1
0
0
# 01's 0
#2's 0
#3's 0
#4's 0
#5's
#0
1's 0
#2's 0
#3's 0
#4's 0
#5's

5. I speak up if I have a patient safety concern. 6. Care team members on this unit feel free to question the decisions or actions of those with more authority.

1
0.9
0.8
1
0.7 5 0.9
0.8
6
0.6
0.7
0.5 0.6
0.4 0.5
0.4
0.3 0.3
0.2 0.2
0.1
0.1 0

#01's 0 0 0 0
0
#2's #3's #4's #5's
#0
1's 0
#2's 0
#3's 0
#4's 0
#5's

7. Important patient care information is exchanged during shift changes. 8. If I have an idea about how to make things better on this unit, the manager and other staff are willing to try it.

1
1
0.9 7 0.9
0.8
8
0.8
0.7 0.7
0.6 0.6
0.5 0.5
0.4 0.4
0.3 0.3
0.2 0.2
0.1 0.1
0 0

# 01's 0
#2's 0
#3's 0
#4's 0
#5's # 01's 0
#2's 0
#3's 0
#4's 0
#5's
 9. Care professionals communicate complete patient information during hand-offs. 10. Essential patient care equipment is in good working condition on this unit.

1
1
0.9 9 0.9
0.8
10
0.8
0.7
0.7
0.6 0.6
0.5 0.5
0.4 0.4
0.3 0.3
0.2 0.2
0.1
0.1
0
0
# 01's 0 0 0 0
# 01's 0 0 0 0
#2's #3's #4's #5's #2's #3's #4's #5's