Clinical Site Evaluation Survey Form
Please complete this survey to provide feedback on your experience at the clinical site. Your responses will help us assess and improve site quality.
Clinical Site Name or ID
*
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your Role
*
Please Select
Student
Faculty
Preceptor
Staff
Other
Site Environment (e.g., safety, comfort, organization)
*
1
2
3
4
5
Staff Professionalism
*
1
2
3
4
5
Communication (clarity, responsiveness, information sharing)
*
1
2
3
4
5
Patient Flow (efficiency, wait times, organization)
*
1
2
3
4
5
Cleanliness and Hygiene
*
1
2
3
4
5
Equipment and Resource Readiness
*
1
2
3
4
5
Overall, how would you rate this clinical site?
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Submit Survey
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