360-DEGREE EVALUATION FORM

This process provides a full-circle view of resident/student skills and abilities by gathering information from various perspectives: the individual and others (peers, supervisors, patients, health care team members). This profile provides a more balanced overview than self-evaluation or peer/supervisor review.
The completed questionnaires will be compiled into a final report for the Fellow.
Please rate the individual based on your recent experience with him/her. Be realistic, honest, and direct. This is a formative evaluation process (one designed to provide feedback for improvement) not a summative one (designed for promotion or retention purposes).

Evaluate where a "5" identifies an average, competent Palliative Medicine Physician who is in practice and out of training
Name: 


  1. Patient and Family Care Competency:
    Gathers accurate & critical information from all pertinent sources.
    1 2 3 4 5 6 7 8 9


  1. Patient and Family Care Competency:
    Care shows attention to age gender, sexual orientation,
    culture, disability
    1 2 3 4 5 6 7 8 9


  1. Patient and Family Competency:
    Care is based on 1) patient & family preference 2) best evidence
    3) clinical judgment
    1 2 3 4 5 6 7 8 9





Abbe Leffel
IL