Questionnaire Part 1

The Questionnaire needs to be completed by the Facilitator / Dementia Lead on behalf of the surgery. (The person is filling in the whole form with the exception of a few questions that they may need to ask someone to give them the answers to).

Questions 1 - 11 will provide WaMH in PC with background information on your surgery and gather information on the relevance of the training to your practice.

Comment boxes are provided for any additional comments you would like to include, which have relevance to the training.

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* 1. Please provide your name and title

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* 2. Name of your surgery

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* 3. Which Health Board(s) do you work in?

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* 4. When did the surgery complete the 'Managing Dementia in Primary Care' training

Date

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* 5. How many people work in your practice team?

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* 6. How many members of staff completed the training, excluding, the Advance Care Planning and End of Life Care module?

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* 7. How many members of staff completed the Advance Care Planning and End of Life Care module?

T