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* 1. Please identify your title.

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* 2. How long have you been practicing as a clinician?

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* 3. Have you received any leadership training or development in the past?

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* 4. If you answered “yes” to question 3, what type of leadership training or development have you received? (include name of training, host organization, and other details)

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* 5. How important do you think leadership skills are in your role as a clinician?

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* 6. What leadership skills do you think are most important for clinicians to have? Please select your top three.

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* 7. Have you ever met a leadership challenge in your role as a leader in a healthcare setting? If so, please describe the challenge and how you handled it.

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* 8. How confident do you feel in your current leadership skills/ as a leader?

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* 9. Would you be interested in participating in a leadership development program for clinicians?

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* 10. If you answered “yes” to question 9, what topics would you like to see covered in such a program? Please select your top three.

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* 11. If you answered "no" to question 9, explain why you do not have a need for a leadership development program at this time.

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* 12. What is your preferred learning environment for leadership development training? Select all that apply.

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* 13. Do you have any additional comments or suggestions about leadership development for clinicians?

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