M4 Student Performance Evaluation Performance Evaluation Preceptor InformationEvaluation Date(Required) MM slash DD slash YYYY Preceptor Name(Required) First Last Preceptor Email(Required) Preceptor Phone(Required)Practice Name(Required)Do you have any conflict of interest in evaluating this student, such as having previously treated the student as a patient or having a family or financial relationship with the student?(Required) Yes No History and Physical Exam SkillsHistory Taking Skills(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation N/A Physical Exam Skills(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation N/A Problem-Solving Skills(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation N/A Ability to apply knowledge(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation N/A Behavior as a StudentIn relation to patients(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation N/A In relation to support personnel(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation N/A In relation to faculty(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation N/A Attendance, participation(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation N/A Appearance(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation N/A Initiative(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation N/A Open ResponseWhat are this student's greatest strengths?What are areas for improvement?Enter any additional commentsBy checking this box, I attest that I have personally supervised and evaluated this student during their clinical rotation and that the information provided in this evaluation is accurate and reflects my professional judgment.(Required) I Agree
