Clinical Placement Nutrition Survey
Please provide your feedback on your recent clinical nutrition placement experience. Your responses will help us improve future placements.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Placement Site/Facility Name
*
Placement Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Placement End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please rate the following aspects of your clinical placement experience.
*
Rows
Excellent
Good
Fair
Poor
Orientation to the facility
1
2
3
4
Support from preceptor/supervisor
5
6
7
8
Variety of nutrition cases encountered
9
10
11
12
Opportunities for hands-on practice
13
14
15
16
Access to resources and materials
17
18
19
20
Feedback and evaluation received
21
22
23
24
How would you rate your overall satisfaction with this clinical placement?
*
1
2
3
4
5
Were you able to meet your learning objectives during this placement?
*
Yes
Partially
No
Which nutrition-specific activities did you participate in? (Select all that apply)
*
Patient nutritional assessments
Menu planning
Nutrition education/counseling
Team meetings/rounds
Research or audit activities
Other
What were the most valuable aspects of your clinical placement?
What suggestions do you have for improving future clinical nutrition placements?
Submit Survey
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