Surgical Technology Clinical Slot Survey
Please complete this survey to help us match you with a clinical slot that best fits your preferences and availability.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Current Program Year
*
Please Select
First Year
Second Year
Third Year
Other
Preferred Clinical Sites (select all that apply)
*
Hospital A
Hospital B
Surgical Center C
Other
Availability for Clinical Rotations
*
Rows
Available
Not Available
Monday Morning
1
2
Monday Afternoon
3
4
Tuesday Morning
5
6
Tuesday Afternoon
7
8
Wednesday Morning
9
10
Wednesday Afternoon
11
12
Thursday Morning
13
14
Thursday Afternoon
15
16
Friday Morning
17
18
Friday Afternoon
19
20
Please indicate your prior clinical experience in surgical technology.
*
No prior experience
Some observation only
Completed a prior rotation
Other
How important are the following factors in your clinical slot assignment?
*
Rows
Not Important
Somewhat Important
Very Important
Proximity to Home
21
22
23
Type of Procedures Performed
24
25
26
Hospital Size
27
28
29
Shift Timing
30
31
32
Familiarity with Staff
33
34
35
Do you have any special requests or circumstances we should consider?
Signature
*
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