Mid-Rotation Feedback Form
Part I: STUDENT SELF-ASSESSMENT
Student’s Name:
Preceptor’s Name
Rotation:______________________________ Rotation Dates: _____________________________ _____
Site:
Students: Please answer these questions before meeting with your preceptor:
Which of the six competencies do you think are your strongest in this rotation (Please list top 3.) What do you think is contributing to your success? (Competencies: Medical Knowledge, Patient Care, Communication Skills, System Based Practice, Professionalisim, and Lifelong Learning Skills)
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Top 3 Competencies Being Performed Well |
Reason for Success |
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1. |
1 |
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2. |
2. |
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3. |
3. |
Which of the competencies do you still need to work on? (Please list at least one.) What will you do to improve your performance in this rotation?
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Clerkship Objective(s) Needing Work |
Plan for Improvement |
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Additional Comments (optional):
____________________________________________________________________________________________
____________________________________________________________________________________________ ____________________________________________________________________________________________
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Mid-Rotation Feedback Form
Part II: PRECEPTOR FEEDBACK
Student’s Name:
Preceptor’s Name
Rotation:____________________________ Rotation Dates: ___________________________________
Site:
PLEASE RATE THE STUDENT IN THE FOLLOWING CATEGORIES USING A 1 - 10 SCALE WITH 1 BEING EXCEPTIONALLY POOR PERFORMANCE AND 10 BEING OUTSTANDING PERFORMANCE:
|
Medical Knowledge |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
|
Patient Care |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
|
Communication Skills |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
|
System Based Practice |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
|
Professionalism |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
|
Lifelong Learning Skills
|
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
|
Strengths: |
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Areas for Improvement:
Comments:
Student’ Signature: Date:
Faculty Signature: Date:
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