This page provides a list of all questions found on the PSRP reporting form for Ambulatory Surgery Centers (ASCs). They are grouped alphabetically by the section of the form in which they appear. This list does not indicate which questions are required for all ASC reports nor which questions only appear for certain event types. A list of required questions can be found here: Required Fields for ASCs.

General Information

Summary, Cause and Action Plan Information

Harm Category

Event Information

HIT Questions

Event Type-Specific Questions

Anesthesia Event-Specific Questions

Blood or Blood Product Event-Specific Questions

Contaminated Drug, Device or Biologic Event-Specific Questions

Device, Equipment or Supply Event-Specific Questions

Fall Event-Specific Questions

HAI Event-Specific Questions

Medication or Other Substance Event-Specific Questions

Surgical or Other Invasive Procedure Event-Specific Questions

Unintended Retained Foreign Object Event-Specific Questions

Contributing Factors

Review and Analysis Information