Destination Profile Survey
Updated: July 26, 2012
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.
PROFILE
1.
Site Name (e.g. XXXX Hospital):
2.
Unit Name and Location (e.g. 1A Maternity):
3.
Unit Type:
4.
Service:
Inpatient
Outpatient
Inpatient &
Outpatient
Community
Medicine
Oncology
Nephrology
Neurology
Surgical Inpatients
Ortho Inpatients
OR
Daycare Surgery
Post Anesthetic Care
Surg Short Stay
Palliative
Psychiatry
Clinics (explain):
Rural Acute (students will rotate through multiple service areas)
Obstetrics AP/PP
Labour/Delivery
Pediatrics
Residential. Care
Special Care
Geriatrics
ER
ICU
CCU
Public Health/Prevention
Home Care
Other Community
(explain):
Nursery/Neonatal
Cardiac Step-down
Other Service area (explain)
5.
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)
6.
Days/ Hours of Operation:
M
T
W
Th
24/7 or
F
S
Su
Hours:
to
7.
Services Offered – please provide a brief description:
8.
Patient/Client/Resident Population – please provide a brief description:
9.
Learning Opportunities that are available to students:
(24 hr format)
HSPnet Destination Profile – Survey
Page 2
Updated: July 26, 2012
10. Do you have any documents you would like to attach to your destination (e.g. required reading, Destination
procedures, etc.)?
Yes
No
If yes, include when forwarding your completed survey.
11. 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
DESTINATION CONTACTS
12. Unit Contacts:
Manager
Name:
Office Email:
Office Phone:
Office Email:
Office Phone:
Title:
Educator
Name:
Primary student placement Contact in your department is the
Name:
Office Email:
Manager
Educator OR:
Office Phone:
Title:
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. Placement Exclusions - Are there any disciplines or types of placement that your unit is unable to
accommodate?
Yes
No
If yes, please list the disciplines/placements types and provide reasons for exclusion:
15. Placement Prerequisites - List any student prerequisites that may be unique to your unit or program (e.g.
Breastfeeding Certificate, personal transportation required, etc.)
16. 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.
Yes
No
HSPnet Destination Profile – Survey
Page 3
Updated: July 26, 2012
Complete the following tables to describe your ability to accommodate different disciplines on your unit for
instructor-led groups and preceptorships:
Instructor-led Group Capacity:
Discipline
Shifts Worked (hours)
Other
8
12
(specify)
Minimum Year of Students
Accepted for Instructor led
Groups
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
Care Aide
Yes
No
1
2
Any
Paramedic
Yes
No
1
2
Any
Unit Clerk / MOA
Yes
No
1
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
17. Please indicate the maximum size of Group (instructor-led) you can accommodate:
Preceptorship Capacity:
Discipline
Shifts Worked
(hours)
8
12
Other
(specify)
Accept
Preceptored
Students?
Minimum Year of
Students Accepted
for Preceptored
xxx?
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
Care Aide
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
Max # of Preceptorships
Available per term
Winter
18. Does your destination accept Masters or post-graduate students?
Spring/
Summer
Yes
Fall
No
19. Other Placement Types - Can your unit or program accommodate:
Observation / Job shadow visits
Fieldwork placements
Co-op students
Collaborative Learning/Teaching Units
Projects
Other (describe):
20. 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.
Thank you completing this survey. Please contact your Receiving Coordinator if you have any questions.