Ontario PIECES Educator Development Program Wait List Survey

Question Title

* 1. Participant Information (required)

First Name *

Last Name *

Email Address: *

Phone Number

Question Title

* 2. Organization Information

Organization Name *

Address:

City/Town

Postal Code

Phone Number

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* 3. What is the LHIN Region where you work? (select one)

Central

Central East

Central West

Champlain

Erie St. Clair

Hamilton Niagara Haldimand Brant

Mississauga Halton

North East

North West

North Simcoe Muskoka

South East

South West

Toronto Central

Waterloo Wellington

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* 4. What is you position (job title) within the organization?

PRC- Psychogeriatric Resource Consultant

Specialty Outreach Team Member

Other

If answered other, please specify

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* 5. What is your professional designation?

RPN

Social Worker

Social Services Worker

Occupational Therapist

Physiotherapist

Nurse Practioner

Recreation Therapist

Other

If answered other please specify:

Question Title

* 6. Have you completed the PIECES Learning and Development Program?

Yes

If yes, please indicate date and location of the the PIECES Program you attended:

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* 7. Please rank each of the 4 learning goals for this program in order of your priority - check one choice per goal:

	First choice	Second choice	Third choice	Fourth choice
Clinical	Clinical First choice	Clinical Second choice	Clinical Third choice	Clinical Fourth choice	Clinical
Adult learning concepts	Adult learning concepts First choice	Adult learning concepts Second choice	Adult learning concepts Third choice	Adult learning concepts Fourth choice	Adult learning concepts
P.I.E.C.E.S. approach	P.I.E.C.E.S. approach First choice	P.I.E.C.E.S. approach Second choice	P.I.E.C.E.S. approach Third choice	P.I.E.C.E.S. approach Fourth choice	P.I.E.C.E.S. approach
Transfer of learning with senior leadership support	Transfer of learning with senior leadership support First choice	Transfer of learning with senior leadership support Second choice	Transfer of learning with senior leadership support Third choice	Transfer of learning with senior leadership support Fourth choice	Transfer of learning with senior leadership support

Please describe any other learning goals you have:

Question Title

* 8. Do you use the PIECES Approach in your ptactice?

Yes

Thank you for your interest in the PIECES Educator Development Program!
You will be contacted by email when the next PIECES Educator Development Program is scheduled.
Please note that there is usually only one session scheduled per year based on demand.