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* 1. What is the name of your educational institution?

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* 2. What is the code for the clinical course you have just completed?

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* 3. What level of education are you completing?

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* 4. In which year of a program are you enrolled? (if a combination, list highest year)

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* 5. Where was your most recent clinical placement?

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* 6. Using the scale below, please respond to the following statements about your placement experience:  

  Strongly Agree Disagree Neither agree nor disagree Agree Strongly Agree
I was fully oriented to the clinical area
Staff were willing to work with students
Staff were positive role models
Staff were ethical and professional
Staff demonstrated respect and empathy towards residents
Resident safety was fundamental to the work of the RHA
I felt valued during my placement
I felt safe in the clinical environment (physically, emotionally, culturally)
The placement was a good learning environment
My supervisor(s) helped me identify my learning objectives/needs
I was adequately supervised in the clinical environment
I received regular and constructive feedback
I was supported to work within my scope of practice
My supervisor(s) understood how to assess my clinical abilities
I had opportunities to enhance my skills and knowledge
I had opportunities to interact and learn with the multi-disciplinary team
I achieved my learning objectives
I have gained the skills and knowledge to further my practice
I anticipate being able to apply my learning from this placement

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* 7. On a scale of 1 - 10, with 1 being very dissatisfied and 10 being extremely satisfied, how satisfied were you with this placement experience?

0 10
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i We adjusted the number you entered based on the slider’s scale.

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* 8. Please provide any additional comments about your placement experience

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