Learning Needs Assessment

You need to complete one assessment for each programme you are interested in pursuing.  It will take about 10-15 minutes to answer all the main questions.  All information you supply will be treated in confidence.

Personal Information

First Name

Last Name

Job Title

Organisation

Preferred Contact Points (where we should send feedback)

Email:

Telephone:

Area of Interest

2.	What topic are you considering?
	Career
	Continual Professional Development
	Communication
	Marketing
	Mediation
	Strategy
	Team (including Team Leader)
	Time management
	Don't know
	Other

	Please add further information below

3.	How did you first hear about Accomplice?
	--Click Here--previous participant in an Accomplice programmeevent run or facilitated by Accompliceattended an other Accomplice programmecolleaguee mail communicationwebsitearticlejournaladvertother

4.	Briefly describe any other events that have raised your need to learn more about this topic?

5.	What development opportunities have you already pursued in relation to this topic?
	Coaching		Conference		Formal course (with qualification)
	Mentoring		Short course (informal, inhouse)		Other  (please specify, using the box below)
	Seminar or workshop		Short course (informal, external)		None

	Please give more information about the opportunities you have had below e.g. name, organisation, content and  your learning

Needs Assessment

6.	Given all you know so far, what would be your main learning priority for this programme?

	What other learning priorities would you have for it?

7.	Outline below any workplace task (and deadline) that you have to deliver in relation to the topic.

8.	What, if any, are your expectations of the trainer (or consultant) who will deliver the programme ?

9.	As part of any programme, how much time could you realistically commit each week to further study?
	--Click Here--noneless than an houran hour1-2 hours3-5 hoursover 5 hours

Access

10.	Highlight any ways in which you would not like study this topic?
	guided support on my own		with people I have not met before		seminar-style (16 - 24 people)
	with 121 support from a consultant		in a small group (up to 4 people)		in a conference setting (over 24 people)
	with my colleagues		in a large group (5 -16 people)		Other

	Add further advice below

11.	Which of the following is your preferred learning style (tick up to two)?
	Activitist		Reflector		Theorist		Pragmatist		Don't know

12.	How do you best learn?  How true are these phrases describe you?
		Very true		True		Partly true		Untrue
	I like new experiences and am enthusiastic about new ideas.
	I tend to act first and consider the consequences later
	I like to look at situations from different perspectives.
	I prefer to collect and consider information and data before drawing your conclusions.
	I like to adapt observations and apply theories.
	I am systematic and logical when thinking through problems.
	I like to try things out.
	I am usually keen (or even impatient) to get to the conclusions.

13.	How much do you enjoy and learn through ...
		lots		quite a lot		a little		not at all
	reading
	doing internet searches
	writing out your ideas
	listening to speakers or lectures
	watching DVDs
	trying our techniques
	watching others at work
	working alone
	completing 'on line' exercises

14.

Are you prepared to travel to a venue for a programme?

Yes

No

Perhaps

	Explain any conditions upon your travelling

	Our premises are fully accessible for people with physical disabilities.  However, should you have any other access requirements that we should be aware of (e.g. visual, audio or learning needs), please state them below.

Fees

15.	How would your programme fees be paid?
	--Click Here--MyselfMy organisationDon't knowOther (describe below)

	Further explanation of how your fees would be paid.

16.	What is the maximum budget (per person) do you have in mind?
	--Click Here--under £25 £25    -  £   49£50    -  £   99£100  -  £ 199£200  -  £ 499£500  -  £ 999over £1, 000Other (describe below)

	Other information

Equal Opportunities Monitoring

17.

To ensure we serve a full range of individuals and communities, would you be prepared to provide the following personal information which will be kept in confidence.

Yes, I am happy to provide personal data

No, I do not want to provide any personal data

17.a

Are you?

male

female

17.b	What is your marital status?
	married		single		divorced		widowed		civil partnership		co-habiting

17.c	What age group do you fall into?
	Under 16		18 - 19		25 - 29		45 - 49		60 - 64
	16 - 17		20 - 24		30 - 44		50 - 59

17.d

Which postcode do you live in?

17.e	Are you:
	A British (United Kingdom) Citizen		An EU national		A refugee		An asylum seeker		a foreign student		other

17.f	Which ethnic group do you belong to?
	White British		Mixed Race: White and Asian		Other Asian or Asian British		Gypsy/Traveller
	White Irish		Other Mixed Race		Caribbean		Other (please specify below)
	White (other)		Indian		African
	Mixed Race: White & Black Caribbean		Pakistani		Any other Black or Black British
	Mixed race: White and Black African		Bangladeshi		Chinese

	Please specify your ethnic group here:-

17.h

Is English your first language?

yes

no

17.i	What is your religion?
	Buddist		Hindu		Muslim		No religion
	Christian		Jewish		Sikh		other (please specify below)

	Please specify your religion here:

17.k	Please indicate if you would consider that you have a :-
	physical impairment such as a wheel chair to get around, difficulty using your arms or legs
	sensory impairment such as being blind or having a serious visual or hearing impairment?
	mental health condition such as depression, dementia, schizophrenia)
	learning disability such as Downs syndrome or dyslexia; or cognitive impairment such as autism or head-injury
	long-standing condition such as cancer, HIV, diabetes, chronic heart disease, epilepsy
	drug or alcohol dependency

17.l

What is your sexual orientation?

Heterosexual ('straight')

Homosexual ('gay' man; 'gay' woman or lesbian)

Bisexual

Feedback on this Activity

18.	Completion of the Activity
	How easy was it to complete this activity?	Easy		Quite Easy		Quite difficult		Difficult

19.	Duration of the Activity
	How long did it take to complete this activity?	0-10min		10-15min		15-30hr		over half an hour

	Provide any other  Comments, Feedback and Advice below

On completion, please print a copy for your future reference (Main Menu: File & Print).

Then, press 'submit' to send a copy to Accomplice.

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