Appendix I: Clinical Clerkship Student Performance Evaluation Form




Clinical Clerkship Student Performance Evaluation

       STUDENT FIRST AND LAST NAME:                                                                                                                                                                    

      Rotation Start Date: ________________   End Date: _____________   ROTATION:                                                               _  

ROTATION LOCATION: _________________________________          CORE______     ELECTIVE______

Evaluator Name:_____________________ Role:  ___Clerkship Director   ___Attending     ___Mentor     __Resident     

                                                                                           Other ____________________


    Please evaluate the performance of the student in the following competencies using the anchors described below: 

Above Expectations

Highly commendable performance, top 5-10% of students evaluated


Meets Expectations

Capable, at expected performance for level


Below Expectations

Demonstrates initial growth; opportunity for improvement



Needs Attention


Cannot Assess

Does not apply to rotation



       Enter Number or N/A

Medical Knowledge: Apply scientific principles and knowledge for effective patient care, diagnosis, management, and prevention of clinical, epidemiologic, social and behavioral problems in patient care and related disciplines.

Assessed Skills: Apply knowledge of study design and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness


Patient Care: Demonstrate the highest level of efficiency in data gathering, organization, interpretation and clinical decision making in the prevention, diagnosis, and management of disease

Assessed Skills: Performs patient interviews; uses judgment; is respectful of patient preference.

Communicate effectively using caring and respectful behaviors when interacting with patients, families and members of the health care team


Practice–Based Learning and Improvement: Understands evidence-based medicine and applies sound principles of practice within the context of patient care.

Assessed Skills: Self-assesses; uses new technology; accepts feedback


Interpersonal and Communication Skills: Demonstrates effective and compassionate interpersonal communication skills toward patients and families necessary to form and sustain effective medical care.  Assessed Skills: Present information and ideas in an organized and clear manner to educate or inform patients, families, colleagues and community. Understand the complexity of communication including nonverbal, explanatory, questioning and writing in a culturally appropriate context.


Professionalism: Display the personal attributes of compassion, honesty and integrity in relationship with patients, families, and the medical community. Adhere to the highest ethical standards of judgment, conduct and accountability as each applies to the health care milieu.

Assessed Skills: Shows compassion, respect, and honesty; accepts responsibility for errors; considers needs of patients/colleagues. Demonstrates a critical self-appraisal in his/her knowledge and practice of medicine.


Systems-Based Practice: Identify the limits of personal knowledge and experience and demonstrate the intellectual curiosity to actively pursue the acquisition of new scientific and clinical knowledge and skills necessary to refine and improve his/her medical practice.

Assessed Skills: Identify methods to obtain and use information about their own population of patients and the larger population from which their patients are drawn






For your information, the calculation for the grade is shown below

Total Number of Points


Number of Competencies evaluated (not marked N/A)


Clerkship Evaluation Grade = Total Points Divided by Number of Competencies Evaluated




Please provide a meaningful narrative relating to the student’s performance. Please describe strengths as well as weaknesses and be as specific as possible. Citing particular examples of behavior provides more robust feedback than do nonspecific remarks such as “good student.”






Do you have any hesitations about this student becoming a physician? _____YES    ____NO  (If YES, please explain on a separate sheet of paper).

       TOTAL DAYS ABSENT:                                TOTAL DAYS TARDY:                 WAS THIS TIME MADE UP:                    YES                  NO


       EVALUATOR’S SIGNATURE:  DATE:                                                                      


        HOSPITAL DME SIGNATURE:                                                                          DATE:                               


Please enclose in a sealed envelope. Mail the original completed form to:

XUSOM North American Representative Office

Attention: Clinical Coordinator

1000 Woodbury Rd. Suite 109 І Woodbury, NY 11797

FAX Number: (516) 921 – 1070 






                     Hospital Seal: