Please complete a separate survey for each preceptor

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* 1. Your name:

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* 2. Office:

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* 3. Which Pediatric Nurse Residency class are you participating in?

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* 4. Please enter the first and last name of your preceptor:

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* 5. Please select the week that you worked with this nurse preceptor:

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* 6. If you have worked with the same preceptor on multiple dates this week please fill in each specific date accordingly.

Date
Date
Date
Date
Date

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* 7. Client's diagnosis ( please do not identify the client by name):

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* 8. Client's age (please do not identify the client by name)::

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* 9. Was the care provided in the home or school?

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* 10. How many times have you previously precepted this client?

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* 11. Please rate the following:

  Strongly disagree Disagree Neutral Agree Strongly agree
1. The preceptor effectively assisted me to achieve my clinical objectives
2. The preceptor fostered my independence in mastering clinical skills
3. The preceptor was organized and prepared
4. The preceptor exhibited professional communication skills that facilitated learning
5. The preceptor modeled culturally sensitive, ethical, and professional behavior
6. The preceptor exhibited a positive attitude toward my training
7. The preceptor provided constructive feedback in a non-judgmental manner
8. The preceptor followed established policy and procedures for all client care

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* 12. Please provide additional comments (i.e., positive feedback or constructive criticism related to your preceptor.) :

T