Two-Week Site Evaluation Form

 

CHS/GMHETC CLERKSHIP ROTATIONS
Two-Week Site Evaluation Form

This form is designed to help CHS/GMHETC evaluate the quality of the sites where students are placed for their clinical rotations. This form must be completed after the first 2 weeks of the rotation in order to make necessary adjustments early in the rotation and make the rotation a worthwhile learning experience for students. **Please be assured that information you provide on this form cannot be used against you in any shape or form and will not have any impact whatsoever on your performance evaluation/grades for this clinical rotation.**

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid entry

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Invalid Input

Please specify whether staff members at the site are receptive to you or not

Please tell us number of patients seen per day.

Please specify whether your preceptor take time to precept you or not

Invalid Input

Please specify whether you are comfortable with your preceptor or not

Invalid Input

Invalid signature address.

(Department Section Only)

Action (CHS/GMHETC): ___________________________________________________________________________________________________

DME/Director of Clerkship Signature: ________________________________________________ 

Date: __________________