Student Evaluation (Form 1)

Student name: …………………………………………………St. Number: …………………

Rotation Starting Date (D/M/Year) : ………./…………./………….….
Rotation Ending Date (D/M/Year) : ………./…………./………….……
Specialty: ……………………………Hospital: ……………………..…………………City:………………..
Hospital telephone: .................................. Department Extension: ………………

Criteria Performance
Un- Below Above Not
satisfactory Average Meet Average Outstanding applicable
(<5) (5-<6) (6-7) (>7- <9) (9-10)
I Knowledge and Academic
activity
Basic science
Clinical science
Participation in scientific
activities
Presenting a scientific topic
II Clinical and Technical Skills
Presenting in morning meetings
Presenting cases in ward rounds
/clinics
Gathering history & performing
Physicals in ward & clinics
Organization of work
Ability to work in a team
Performing bedside procedures
Care&Follow up of patients
Collecting lab and radiology
results
Interpretation of results
Participation in CODE BLUE
and TRAUMA CODE
III ATTITUDE and ETHICS
Discipline
Reliability
Ethics standards
TOTAL SCORE
Comments: ……………………………………………………………………………………………………….
………………………………………………………………………………………………………………………
Evaluator Name: …………………………………………. Position/Degree: ………………………….…………
Office extension:……………..Email:……………………………Signature & Stamp:………………………...
 Student Evaluation (Form 2)
Student name: …………………………… …… ……… ……… St. Number: …………………
Rotation Starting Date (D/M/Year): ……… ./… ………./………….….
Rotation Ending Date (D/M/Year): ………./…………./………….……
Specialty: ………………………………Hospital: ……………………....…………………City:……… ………..
Hospital telephone: ........................................... Department Extension: ………………

ATTITUDE & ETHICSEVALUATION

Student inter-professional relations

with with with with with Patients'
superiors colleagues nurses hosp. staff patients relatives
& workers
1 Head of Department
Name:

Extension: …… / 10 …… / 10 …… / 10 …… / 10 …… / 10 …… / 10
Signature:

2 Attending Physician
Name:

Extension: …… / 10 …… / 10 …… / 10 …… / 10 …… / 10 …… / 10
Signature:

3 Nurse in charge in ward/

clinic
Name:
XXX XXX …… / 10 …… / 10 …… / 10 …… / 10
Extension:
Signature:

4 Training Department Comments and recommendation:

Name: ………………………………………………………………………………
………………………………………………………………………………
Extension: ………………………………………………………………………………
Signature: ………………………………………………………………………………
………………………………………………………………………………

Hospital Stamp: