PRECEPTOR FEEDBACK FORM - COMMUNITY CLINIC EXPERIENCE

MS1 #6 Self-Directed Learning Clinic Experience

Students name: __________________________________________

Preceptor's signature: ________________________________

Date & time of visit: ______________________________________

Preceptors name: _______________________________________

Instructions for Preceptor: Thank you for participating in the community and clinical experiences program at the Paul L. Foster School of Medicine. Your
participation provides our students with valuable opportunities to learn in the real world. We know your time is valuable but we would like brief feedback from
you about the student's performance today. For each statement, please circle the appropriate descriptors
Criterion
Timeliness
On time
Arrived late
Left early
Dress
Appropriate
Inappropriate
Respectful conduct
Respects beliefs, rights, roles, abilities,
Disrespectful of Patients, Staff, Preceptor
and values of Patients, Staff, Preceptor
Spanish
Excellent
Practiced while
Did not use any Spanish
Not applicable
here
Skills (history taking)
Better than expected What I expected
Worse than I expected
Not applicable
Communication with
Courteous
Discourteous
Insulting
you, staff & patients
Respectful
Disrespectful
Patronizing
Appropriate Vocabulary
Uses Jargon with Pts
Does not answer pt
questions
Professionalism
Maintains Confidentiality
Discloses information where might be
Discloses information in
overheard
public setting
Maintains professional boundaries
Egregious boundary
Honest
Minor boundary violations
violations
Behaves with equity to all pts
Stretches truth
Lies outright
Does not treat all patients equally
Publically discriminates
PRECEPTOR COMMENTS:
List two things the student did well during this visit.

List two things the student needs to improve.

STUDENT COMMENTS: Based on the preceptors feedback, reflect and briefly list and describe strategies for improvement.