Education Off-site Needs Assessment Form

Name of the Organisation*

Contact Information:

Title*
MrMsMiss

First Name*

Last Name*

Adress

Phone No*

Email*

Requested Education/Training Topic*

Preferred dates requested*

Preferred Start/finish times*

Number of participants*

Participants roles*

What care areas/institutions are participants working in*

With reference to our course programme (see website) – regarding related course learning objectives - please outline any additional specific learning requirements that you wish to be included in the study day/course

If the course, study day, that you are requesting is not outlined in our course program, could you please outline your learning objectives for each type of education/training requested

Do you have laptop, projector & TV, DVD available?
YesNo

Are there car parking facilities available?
YesNo

Please outline the location & cost of car parking for the day if applicable

What existing local guidelines/policies are available in your area to provide ongoing support for participants with this particular care component, course or study day request? Please indicate if there is an absence of same