This article describes the methodological procedure followed in the design and validation of the survey instrument applied among service Providers at First-level Assistance Centers - run by the Regional Healthcare Department (GERESA) in Lambayeque, Peru-with the aim to evaluate the factors that prevent them from making innovation. This survey instrument was designed to meet one of the specific objectives established on the research project entitled Potential Demand in the Research Conducted by University Professors in order to Increase the Technological Innovation in the Social and Productive Sectors in Lambayeque, Peru, 2014 - 2020. This study was initiated at Universidad Nacional Pedro Ruiz Gallo (UNPRG) in Lambayeque, Peru, and continued within the Postdoctoral Program "Education in the Knowledge Society" at University of Salamanca, Spain. The criteria for the survey design were the following: Literature review, drawing of an explanatory hypothesis, expert interviews, survey testing and interaction with stakeholders, final design, and permission request to apply the final survey instrument. Students of the Management Information Systems class at UNPRG Management School gave their academic support throughout these stages.