Receiving Agency Profiles - Destination Survey Tool for Receiving Coordinators

Receiving Agency Related Guide (RARG)

Summary:
The purpose of this survey is to collect Destination Profile information including a description of target placement capacity for each unit or program under your responsibility. Save a local copy of this form for each destination, and complete the form by clicking or tabbing to each entry.

Click here for the editable word version of this survey.

Site Name (e.g. XXXX Hospital):

Unit Name and Location (e.g. 2 south, Day Surgery):

PROFILE

1. Unit Type: Inpatient Outpatient Inpatient & Community

Outpatient

2. Service (e.g. medicine, physiotherapy, pharmacy, etc.):

3. Unit or Program Activity

Number of beds typically open - if needed, please provide a breakdown beds for mixed units. (e.g.: Obstetrics – 10 beds; Labour & Delivery – 8 beds: Postpartum – 10 beds):
Or (as alternative to # beds): Annual unit activities (e.g. ER visits, clinic procedures)

4. Days/ Hours of Operation:

24/7 or
M T W Th F S Su Hours: to (24 hr format)

5. Services Offered – please provide a brief description:

6. Patient/Client/Resident Population – please provide a brief description:

7. Learning Opportunities that are available to students:

8. Please feel free to add any comments or information regarding your destination that you think would be valuable to the educational institutions when planning upcoming placement requests.

9. Placement Prerequisites - List any student prerequisites that may be unique to your unit or program and not included those common prerequisites included in the affiliation agreements (e.g. Breastfeeding Certificate, personal transportation required, language, etc.)

10. Unit or Program Closures – Please list known or planned upcoming closures:

Type of closure (e.g. construction, Christmas)	Start date of closure	End date of Closure

11. Do you have any documents you would like to attach to your destination (e.g. required reading, Destination procedures, etc.)?

If yes, include when forwarding your completed survey.

DESTINATION CONTACTS

12. Unit Contacts:

Manager Name:
Office Email:
Office Phone:
Title:

Educator Name:
Office Email:
Office Phone:

Primary student placement Contact in your department is the

Manager
Educator
OR:

Name:
Office Email:
Office Phone:
Title:

Other contact or Discipline Contact in your department is the

Manager
Educator
OR:

PLACEMENT CAPACITY

13. Please indicate the maximum number of learners that your unit can accommodate (including students in instructor-led groups and preceptorships) due to space, patient/client population, and other considerations:

14. Will this destination have the exact same capacity as another destination in your site?

If yes, please provide the name of the destination and the profile may be copied.

15. Placement Exclusions - Are there any disciplines or types of placement that your unit is unable to accommodate?

If yes, please list the disciplines/placements types and provide reasons for exclusion:

16. Complete the following tables to describe your ability to accommodate different disciplines on your unit for preceptorships and instructor-led groups:

Preceptorship Capacity:

Discipline	Shifts Worked (hours)			*Accept Preceptored* Students?**	Minimum Year of Students Accepted for Preceptored xxx?	Max # of Preceptorships Available per term
Discipline	8	12	Other (specify)	*Accept Preceptored* Students?**		Winter	Spring/ Summer	Fall
BSN/BScN (RN)				Yes No	1 2 3 4
Specialty Nurse				Yes No	1 2 3 4
Psychiatric Nurse				Yes No	1 2 3 4
Practical Nurse				Yes No	1 2
HCA/RCA				Yes No	1 2
Paramedic				Yes No	1 2
Unit Clerk / MOA				Yes No	1
Other				Yes No	1 2 3 4
Other				Yes No	1 2 3 4
Other				Yes No	1 2 3 4
Other				Yes No	1 2 3 4

17. Instructor-led Group Capacity:

Discipline	Shifts Worked (hours)			Maximum Group Size	*Accept Instructor led Group* Students?**	Minimum Year of Students Accepted for Instructor led Groups
Discipline	8	12	Other (specify)	Maximum Group Size	*Accept Instructor led Group* Students?**
BSN/BScN (RN)					Yes No	1 2 3 4 Any
Specialty Nurse					Yes No	1 2 3 4 Any
Psychiatric Nurse					Yes No	1 2 3 4 Any
Practical Nurse					Yes No	1 2 Any
HCA/RCA					Yes No	1 2 Any
Other					Yes No	1 2 3 4 Any
Other					Yes No	1 2 3 4 Any
Other					Yes No	1 2 3 4 Any

Does your destination accept Masters or postgraduate students?

Thank you completing this survey. Please contact your Receiving Coordinator if you have any questions.