Practicum: Profile + Pre-Survey

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* 2. At what email address would you like to be contacted? (We will ask you to fill out a Post-Survey and send a reminder to fill it out)

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* 3. What's your current health profession?

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* 4. What version of our practicum are you completing?

Complete Practicum (Modules + Experiential Visit(s) + Virtual Debrief)

Abbreviated Practicum (Modules + Virtual Debrief)

Modules Only

Other (please specify)

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* 5. Please note which -if any- Area Agency on Aging you working with for the Practicum.

ADS: Aging and Disability Services - Seattle-King County

AAADSW: Area Agency on Aging and Disabilities of Southwest Washington - Vancouver, WA (and beyond)

SE ALTC: Southeast Washington Aging and Long Term Care - Yakima, WA (and beyond)

Other (please specify)

None of the above

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* 6. Which -if any- training program are you affiliated with?

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* 7. What setting do you currently work -or train- in (mark all that apply)?

Primary Care Setting

Medically Underserved Community (MUC)

Rural Area

Tribal or Tribal Organization

None of the Above

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* 8. How many patients over 65 years of age have you cared for in a typical month?

1-10

11-20

21-30

30+

Not Applicable

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* 9. How confident are you with the following?

	1 - Not at all Confident	2	3	4	5 - Confident	6	7	8	9	10 - Totally Confident
Describing the roles of an AAA	Describing the roles of an AAA 1 - Not at all Confident	Describing the roles of an AAA 2	Describing the roles of an AAA 3	Describing the roles of an AAA 4	Describing the roles of an AAA 5 - Confident	Describing the roles of an AAA 6	Describing the roles of an AAA 7	Describing the roles of an AAA 8	Describing the roles of an AAA 9	Describing the roles of an AAA 10 - Totally Confident
How to locate an AAA for any patient in the US	How to locate an AAA for any patient in the US 1 - Not at all Confident	How to locate an AAA for any patient in the US 2	How to locate an AAA for any patient in the US 3	How to locate an AAA for any patient in the US 4	How to locate an AAA for any patient in the US 5 - Confident	How to locate an AAA for any patient in the US 6	How to locate an AAA for any patient in the US 7	How to locate an AAA for any patient in the US 8	How to locate an AAA for any patient in the US 9	How to locate an AAA for any patient in the US 10 - Totally Confident
Describing the role of an AAA case manager in the care of older adults	Describing the role of an AAA case manager in the care of older adults 1 - Not at all Confident	Describing the role of an AAA case manager in the care of older adults 2	Describing the role of an AAA case manager in the care of older adults 3	Describing the role of an AAA case manager in the care of older adults 4	Describing the role of an AAA case manager in the care of older adults 5 - Confident	Describing the role of an AAA case manager in the care of older adults 6	Describing the role of an AAA case manager in the care of older adults 7	Describing the role of an AAA case manager in the care of older adults 8	Describing the role of an AAA case manager in the care of older adults 9	Describing the role of an AAA case manager in the care of older adults 10 - Totally Confident
Identifying community resources that support unpaid caregivers (e.g. family members)	Identifying community resources that support unpaid caregivers (e.g. family members) 1 - Not at all Confident	Identifying community resources that support unpaid caregivers (e.g. family members) 2	Identifying community resources that support unpaid caregivers (e.g. family members) 3	Identifying community resources that support unpaid caregivers (e.g. family members) 4	Identifying community resources that support unpaid caregivers (e.g. family members) 5 - Confident	Identifying community resources that support unpaid caregivers (e.g. family members) 6	Identifying community resources that support unpaid caregivers (e.g. family members) 7	Identifying community resources that support unpaid caregivers (e.g. family members) 8	Identifying community resources that support unpaid caregivers (e.g. family members) 9	Identifying community resources that support unpaid caregivers (e.g. family members) 10 - Totally Confident
Describing community resources that help maintain an older adult’s independence	Describing community resources that help maintain an older adult’s independence 1 - Not at all Confident	Describing community resources that help maintain an older adult’s independence 2	Describing community resources that help maintain an older adult’s independence 3	Describing community resources that help maintain an older adult’s independence 4	Describing community resources that help maintain an older adult’s independence 5 - Confident	Describing community resources that help maintain an older adult’s independence 6	Describing community resources that help maintain an older adult’s independence 7	Describing community resources that help maintain an older adult’s independence 8	Describing community resources that help maintain an older adult’s independence 9	Describing community resources that help maintain an older adult’s independence 10 - Totally Confident
Referring older adults to AAA resources	Referring older adults to AAA resources 1 - Not at all Confident	Referring older adults to AAA resources 2	Referring older adults to AAA resources 3	Referring older adults to AAA resources 4	Referring older adults to AAA resources 5 - Confident	Referring older adults to AAA resources 6	Referring older adults to AAA resources 7	Referring older adults to AAA resources 8	Referring older adults to AAA resources 9	Referring older adults to AAA resources 10 - Totally Confident
Describing community resources available to support those with dementia and their caregivers	Describing community resources available to support those with dementia and their caregivers 1 - Not at all Confident	Describing community resources available to support those with dementia and their caregivers 2	Describing community resources available to support those with dementia and their caregivers 3	Describing community resources available to support those with dementia and their caregivers 4	Describing community resources available to support those with dementia and their caregivers 5 - Confident	Describing community resources available to support those with dementia and their caregivers 6	Describing community resources available to support those with dementia and their caregivers 7	Describing community resources available to support those with dementia and their caregivers 8	Describing community resources available to support those with dementia and their caregivers 9	Describing community resources available to support those with dementia and their caregivers 10 - Totally Confident

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* 10. I rate my ___________________ for Age-Friendly Care (4Ms: what Matters Most, Medications, Mentation, Mobility)

	1 (Low)	2	3	4	5 (High)
Knowledge	Knowledge 1 (Low)	Knowledge 2	Knowledge 3	Knowledge 4	Knowledge 5 (High)
Confidence	Confidence 1 (Low)	Confidence 2	Confidence 3	Confidence 4	Confidence 5 (High)

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* 11. How often are you currently referring community-based resources to older patients?

Never

Rarely

Sometimes

Often

Always

Not Applicable (I'm not seeing patients or other reason)

Never

Rarely

Sometimes

Often

Always

Not Applicable (I'm not seeing patients or other reason)

Practicum: Profile + Pre-Survey

Northwest Geriatrics Workforce Enhancement Center

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* 1. What is your name (First and Last)?

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* 2. At what email address would you like to be contacted? (We will ask you to fill out a Post-Survey and send a reminder to fill it out)

Question Title

* 3. What's your current health profession?

Question Title

* 4. What version of our practicum are you completing?

Question Title

* 5. Please note which -if any- Area Agency on Aging you working with for the Practicum.

Question Title

* 6. Which -if any- training program are you affiliated with?

Question Title

* 7. What setting do you currently work -or train- in (mark all that apply)?

Question Title

* 8. How many patients over 65 years of age have you cared for in a typical month?

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* 9. How confident are you with the following?

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* 10. I rate my ___________________ for Age-Friendly Care (4Ms: what Matters Most, Medications, Mentation, Mobility)

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* 11. How often are you currently referring community-based resources to older patients?