Student Performance Evaluation Form - Utmb School of Medicine Ambulatory Community Selective

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♦FACULTY PRECEPTOR: RETURN EVALUATION TO YOUR DEPT SELECTIVES COORDINATOR NO LATER THAN THE LAST DAY OF THE PERIOD♦
Student Performance Evaluation Form
UTMB School of Medicine Ambulatory Community Selective
Student Name:
Student PID #:
Selective Period:
Instructor Name:
Selective Name:
Selective Course #:
This form must be completed by the student’s faculty supervisor for the student to receive a final grade. All ratings of ‘Exceeds’
or ‘Below’ expected level of performance must be accompanied by explanatory comments. Please note this information may
be included in the Medical Student Performance Evaluation (Dean’s Letter of Evaluation).
1. Knowledge Acquisition Skills – How well does the student independently seek information, identify relevant sources, use a
variety of sources (including technology when appropriate), critically analyze resources, refer to and appraise relevant information
appropriately, and/or is prepared for discussions or elective activities?
Comment required to justify any rating above or below expected level of performance:
Exceeds expected level of performance
_____________________________________________________________
At expected level of performance
_____________________________________________________________
Below expected level of performance
_____________________________________________________________
Cannot evaluate this item
_____________________________________________________________
2. Problem-solving Skills - How well does the student integrate basic science and clinical concepts, demonstrate
understanding of concepts and issues as they apply to the problem or concept at hand, critically revise hypotheses or strategy
towards approaching the problem, derive differential diagnoses and treatment plans, and/or define differences in normal and
abnormal conditions?
Comment required to justify any rating above or below expected level of performance:
Exceeds expected level of performance
_____________________________________________________________
At expected level of performance
_____________________________________________________________
Below expected level of performance
_____________________________________________________________
Cannot evaluate this item
_____________________________________________________________
3. Communication Skills - How well does the student express relevant information about concepts, ask questions, balance
listening and speaking, and/or qualify personal commentary as such among healthcare team members and patients?
Comment required to justify any rating above or below expected level of performance:
Exceeds expected level of performance
_____________________________________________________________
At expected level of performance
_____________________________________________________________
Below expected level of performance
_____________________________________________________________
Cannot evaluate this item
_____________________________________________________________
4. Professionalism – How well does the student accept and use feedback, recognize and abstain from academic dishonesty,
demonstrate respect and courtesy to peers, staff, patients and faculty, demonstrate sensitivity to gender/ethnicity/cultural issues
when raised, and/or is punctual and attends all meetings as well as protects healthcare information?
Comment required to justify any rating above or below expected level of performance:
Exceeds expected level of performance
_____________________________________________________________
At expected level of performance
_____________________________________________________________
Below expected level of performance
_____________________________________________________________
Cannot evaluate this item
_____________________________________________________________
5. Clinical Interaction/Data Gathering Skills – How thorough and accurate are patient interviews, physical exams, patient
education/counseling, oral patient presentation to faculty/peers, and written documentation?
Comment required to justify any rating above or below expected level of performance:
Exceeds expected level of performance
_____________________________________________________________
At expected level of performance
_____________________________________________________________
Below expected level of performance
_____________________________________________________________
Cannot evaluate this item
_____________________________________________________________
6. Technical Skills – How well does the student acquire and demonstrate the following skills: procedures appropriate to the
clinical setting, research (laboratory) techniques?
Comment required to justify any rating above or below expected level of performance:
Exceeds expected level of performance
_____________________________________________________________
At expected level of performance
_____________________________________________________________
Below expected level of performance
_____________________________________________________________
Cannot evaluate this item
_____________________________________________________________
♦FACULTY PRECEPTOR: RETURN EVALUATION TO YOUR DEPT SELECTIVES COORDINATOR NO LATER THAN THE LAST DAY OF THE PERIOD♦
Student Performance Evaluation Form
UTMB School of Medicine Ambulatory Community Selective
Student Name:
Student PID #:
Selective Period:
Instructor Name:
Selective Name:
Selective Course #:
This form must be completed by the student’s faculty supervisor for the student to receive a final grade. All ratings of ‘Exceeds’
or ‘Below’ expected level of performance must be accompanied by explanatory comments. Please note this information may
be included in the Medical Student Performance Evaluation (Dean’s Letter of Evaluation).
1. Knowledge Acquisition Skills – How well does the student independently seek information, identify relevant sources, use a
variety of sources (including technology when appropriate), critically analyze resources, refer to and appraise relevant information
appropriately, and/or is prepared for discussions or elective activities?
Comment required to justify any rating above or below expected level of performance:
Exceeds expected level of performance
_____________________________________________________________
At expected level of performance
_____________________________________________________________
Below expected level of performance
_____________________________________________________________
Cannot evaluate this item
_____________________________________________________________
2. Problem-solving Skills - How well does the student integrate basic science and clinical concepts, demonstrate
understanding of concepts and issues as they apply to the problem or concept at hand, critically revise hypotheses or strategy
towards approaching the problem, derive differential diagnoses and treatment plans, and/or define differences in normal and
abnormal conditions?
Comment required to justify any rating above or below expected level of performance:
Exceeds expected level of performance
_____________________________________________________________
At expected level of performance
_____________________________________________________________
Below expected level of performance
_____________________________________________________________
Cannot evaluate this item
_____________________________________________________________
3. Communication Skills - How well does the student express relevant information about concepts, ask questions, balance
listening and speaking, and/or qualify personal commentary as such among healthcare team members and patients?
Comment required to justify any rating above or below expected level of performance:
Exceeds expected level of performance
_____________________________________________________________
At expected level of performance
_____________________________________________________________
Below expected level of performance
_____________________________________________________________
Cannot evaluate this item
_____________________________________________________________
4. Professionalism – How well does the student accept and use feedback, recognize and abstain from academic dishonesty,
demonstrate respect and courtesy to peers, staff, patients and faculty, demonstrate sensitivity to gender/ethnicity/cultural issues
when raised, and/or is punctual and attends all meetings as well as protects healthcare information?
Comment required to justify any rating above or below expected level of performance:
Exceeds expected level of performance
_____________________________________________________________
At expected level of performance
_____________________________________________________________
Below expected level of performance
_____________________________________________________________
Cannot evaluate this item
_____________________________________________________________
5. Clinical Interaction/Data Gathering Skills – How thorough and accurate are patient interviews, physical exams, patient
education/counseling, oral patient presentation to faculty/peers, and written documentation?
Comment required to justify any rating above or below expected level of performance:
Exceeds expected level of performance
_____________________________________________________________
At expected level of performance
_____________________________________________________________
Below expected level of performance
_____________________________________________________________
Cannot evaluate this item
_____________________________________________________________
6. Technical Skills – How well does the student acquire and demonstrate the following skills: procedures appropriate to the
clinical setting, research (laboratory) techniques?
Comment required to justify any rating above or below expected level of performance:
Exceeds expected level of performance
_____________________________________________________________
At expected level of performance
_____________________________________________________________
Below expected level of performance
_____________________________________________________________
Cannot evaluate this item
_____________________________________________________________
7. Written Assignment – If applicable, did the student complete the written assignment and turn it in for your evaluation?
Comment required to justify any rating above or below expected level of performance:
Completed
_____________________________________________________________
Not completed
_____________________________________________________________
Please comment on the student’s depth of thought on this written assignment:
Comment required to justify any rating above or below expected level of performance:
Exceeds expected level of performance
_____________________________________________________________
At expected level of performance
_____________________________________________________________
Below expected level of performance
_____________________________________________________________
Cannot evaluate this item
_____________________________________________________________
8. Comments regarding summary of student performance / goals for future development:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Number of student absences during 4-week period: _____________
Your signature confirms that this student spent at least 50% of their time in the clinical setting.
Instructor Signature: ______________________________
Date: ___________________________
Campus Faculty Only:
Written Assignment – If applicable, did the student complete the written assignment and turn it in for your evaluation?
Comment required to justify any rating above or below expected level of performance:
Completed
__________________________________________________________
Not completed
__________________________________________________________
Please comment on the student’s depth of thought on this written assignment:
Comment required to justify any rating above or below expected level of performance:
Exceeds expected level of performance
__________________________________________________________
At expected level of performance
__________________________________________________________
Below expected level of performance
__________________________________________________________
Cannot evaluate this item
__________________________________________________________
Additional Comments:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
FINAL GRADE
__________ Satisfactory
__________ Fail
(Check one)
Course Director Signature: _________________________
Date: ___________________________

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