End of Rotation Evaluation
Name (optional): 


A red asterisk (*) indicates required questions.

  1. Name of Housestaff:*


  1. Please indicate the setting of the rotation.*
    In Patient Consultation Service
    Home and Long Term Care Service
    Inpatient Unit
    Ambulatory Clinic
    Other


  1. Faculty Member Completing this Survey:*


  1. Please list the dates you worked with the student.*


  1. Please rate the student/resident/fellow on the following behaviors. Reliability and Responsibility:*

            1 2 3 4 5       N/A
      Attendance and punctuality This student needs further education or assistance with the following This student has exhibited exemplary behavior in the following area  
      Completing assignments on time (including charting and dictation)  This student needs further education or assistance with the following This student has exhibited exemplary behavior in the following area  
      Notification of abscence for required activities This student needs further education or assistance with the following This student has exhibited exemplary behavior in the following area  


  1. Please rate the student/resident/fellow on the following behaviors. Self Improvment and Adaptability:*

            1 2 3 4 5       N/A
      Acceptance of feedback and contructive criticism This student needs further education or assistance with the following This student has exhibited exemplary behavior in the following area  
      Recognition of limitations and willingness to seek help This student needs further education or assistance with the following This student has exhibited exemplary behavior in the following area  
      Incorporation of feedback This student needs further education or assistance with the following This student has exhibited exemplary behavior in the following area  
      Adaptability to change This student needs further education or assistance with the following This student has exhibited exemplary behavior in the following area  
      Maintaining professional composure in stressful situations This student needs further education or assistance with the following This student has exhibited exemplary behavior in the following area  


  1. Please rate the student/resident/fellow on the following behaviors. Relationships with students, faculty, staff and patients:*

            1 2 3 4 5       N/A
      Establishing rapport This student needs further education or assistance with the following This student has exhibited exemplary behavior in the following area  
      Being sensitive to the needs of patients This student needs further education or assistance with the following This student has exhibited exemplary behavior in the following area  
      Establishing and maintaining appropriate boundaries in work and learning situations This student needs further education or assistance with the following This student has exhibited exemplary behavior in the following area  
      Maintaining respectful and courteous manner with fellow students, faculty, staff, patients and patients' families This student needs further education or assistance with the following This student has exhibited exemplary behavior in the following area  


  1. Please rate the student/resident/fellow on the following behaviors. Upholding the principles of the Professional Code of Conduct:*

            1 2 3 4 5       N/A
      Showing respect for all people equally without regard to age, race, gender, religion, ethnicity, disability, social status, sexual orientation or political ideology This student needs further education or assistance with the following This student has exhibited exemplary behavior in the following area  
      Maintaining professional language, deportment and appearance This student needs further education or assistance with the following This student has exhibited exemplary behavior in the following area  
      Respecting patient confidentiality This student needs further education or assistance with the following This student has exhibited exemplary behavior in the following area  
      Maintaining honesty and integrity This student needs further education or assistance with the following This student has exhibited exemplary behavior in the following area  
      Contributing to an atmosphere conducive to learning This student needs further education or assistance with the following This student has exhibited exemplary behavior in the following area  
      Resolving conflicts in a manner that respects the dignity of every person involved This student needs further education or assistance with the following This student has exhibited exemplary behavior in the following area  


  1. Comments and Suggestions for this student/resident/fellow.





Abbe Leffel
IL