Student/ Intern Feedback Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Prospective Graduation Date:
-
Month
-
Day
Year
Date
Department
Please Select
Speech
Physical Therapy
Occupational Therapy
Name of Supervisor(s)
Overall, how would you rate your experience at Southland?
Excellent
Very good
Good
Fair
Poor
How would you rate the working relationship with your supervisor(s)?
Excellent
Very good
Good
Fair
Poor
How well did the job duties you were given match your knowledge and skills?
Extremely well
Very well
Somewhat well
Not so well
Not at all well
How comfortable did you feel asking questions throughout your internship?
Extremely comfortable
Somewhat comfortable
Not at all comfortable
How interested would you be in pursuing employment at Southland?
Extremely interested
Somewhat interested
Not at all interested
How much did you learn from your time at Southland?
I didn't learn anything new
1
2
3
4
I learned more than expected
5
1 is I didn't learn anything new, 5 is I learned more than expected
How likely it is that you would recommend a friend/ colleague to intern with us?
Not Likely
1
2
3
4
Extremely Likely
5
1 is Not Likely, 5 is Extremely Likely
Anything you would like to share about your experience?
What suggestions could you offer to better our clinic?
(In your experience, what did Southland do well and what could we improve?)
Submit
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