Confidential Clinical Clerkships/Rotations Survey

* indicates required field

Please submit one survey per clerkship/rotation. Only submit the form below if you are completing rotations which started prior to the beginning of 2015. Summaries of clerkship/rotation evaluations completed by students will be provided to program directors and clinical deans.

Student Information

Course *:

Dates of Rotation:

Indicate Location *:

A. COMPLIANCE WITH ESSENTIALS:(rate only current clerkship)

1. Teaching Rounds, 3 Times/Week *:

Conferences, 3 Times/Week *:

H & P’s, 3-5 Times/Week *:

H & P’s Corrected *:

H & P’s Contain Written Plan *:

Doing Procedures *:

Call Q 3-7 Days *:

Can Use Library Evenings/Weekends *:

Did a supervising physician directly observe your clinical skills, such as taking a history or performing parts of the physical examination, during this rotation?:

B. COMMENTS:(Include narrative comments and explanation of ratings)

C. FACULTY EVALUATION:(Rate only teachers with whom you have had regular personal contact.)

Faculty 1

Faculty 2

Faculty 3

Faculty 4

D. OVERALL EVALUATION: Please rate your Rotation as a whole.