SGU OFFICE USE ONLY ST.

GEORGES UNIVERSITY SCHOOL OF MEDICINE GRENADA, WEST INDIES Holiday: _______________ CRN #: _______________ ID #: _______________

CERTIFICATION OF COMPLETED ELECTIVE or SUBINTERNSHIP ROTATION

STUDENTS NAME HOSPITAL NAME ELECTIVE DATES OF ROTATION
(Month/Day/Year)

SSN ADDRESS
(City & State)

POSTGRAD PROGRAM to
(Month/Day/Year)

# OF WEEKS

Using specific examples, comment on the students academic performance, professional behavior, rapport with staff and patients, motivation, attendance and any other aspects of their performance during the rotation:

Constructive Comments (not for use in MSPE):

MEDICAL KNOWLEDGE CLINICAL SKILLS PROFESSIONAL BEHAVIOR

FINAL GRADE: (circle one)

PASS

FAIL

EVALUATOR
Name and Title (Please Type or Print )

Affix Official Hospital Seal

Signature

Date

Director of Medical Education Over Signatures OR Notarize Here Signature

Name and Title (Please Type or Print )

Date

Please note that students have the right to view the contents of this evaluation. Return this Form to: Office of Clinical Studies, University Support Services, LLC., 3500 Sunrise Hwy, Bldg. 300, Great River, NY 11739

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