1

UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

DAILY STUDENT ANECDOTAL NOTE

Student's Name: Li~ir+CP() M{J°' Date: <g / ZCl/t;,:

Course fieJ 2-:1?t J:. Semester_ _?
____ Assigned unit: 3 w"
Number of hours worked on unit: {Oh~
CLINICAL PRECEPTOR:
AboveAi'ge Average Below Average NIA
Motivation to Learn
Patient Assessment
Skills
Safety
Documentation
Professionalism

Comments:

Preceptor Namecz~~~~i{_~..._.*4_1:::_~,.;..J_~~- - - - - + - - - - - -
(Please Print)
Preceptor Signature:l--~~~~~~~'L-1'~~~--'~~~-------

STUDENT EVALUATION OF PRECEPTOR:

Average

r
Check all that apply Above~rage Below Average
Knowledgeable
Encouraged learning
Sup'p ortive
Acts as role model
Professionalism

Comments :

CLINICAL FACULTY:

Agree/Disagree with evaluations.

Comments (including preceptor feedback):

Clinical Faculty Signature_ _ _ _ _ _ _ _ __

Student s;goatu,e~

Revi sed May 2012

---·· 1

UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

DAILY STUDENT ANECDOTAL NOTE

Student's Name: i1-fJ ,1),,-se,v-. &:') Date: qjf /\ i-

Course t:½! SN1Je J: Semester 2,, Assigned unit: JV
Number of hours worked on unit:

CLINICAL PRECEPTOR:
Above Average Average Below Average NIA
Motivation to Learn
Patient Assessment
Skills
Safety
Documentation
·-.:, Professionalism
O'

M
a B
O
B
0
Comments: tXtyemLl A" ~trrw)_ l()it¾ 1w/v1 {µ'\J)_

Preceptor Name: T i ~
(Please Print) - -. •
Preceptor Signature:~ ~

STUDENT EVALUATION OF PRECEPTOR:

Check all that apply Above~erage Average Below Average

Knowledgeable
Encouraged learning
Supportive
Acts as role model
Professionalism
r
Comments:

CLINICAL FACULTY:

e i s agree with evaluations.

Comments (including preceptor feedback):

C linical Faculty Signatu re_ _ _ _ _ _ _ _ __

s1,d,,1 s;g.,..,~ -

Revised May 201 2

 1

UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

DAILY STUDENT ANECDOTAL NOTE

Student' s Name: - ~ ---'i_o_.-.__H

J.-,.;..'.:. .M ..~
:;">-~_.__ Date: ':\ {µ/
j
11
Course ~f'hrl 1 Semester_ ___ 1____ Assigned unit: { V

Number of hours worked on unit: JjL_

CLINICAL PRECEPTOR:
Average Below Average NIA
Motivation to Learn
Patient Assessment 8;
Skills
Safety
Documentation
Professionalism

STUDENT EVALUATION OF PRECEPTOR:

Check all that apply Average Below Average

Knowledgeable
Encouraged learning
Supportive
Acts as role model
Professionalism

Comments:

CLINICAL FACULTY:

Agree/Disagree with evaluations.

Comments (including preceptor feedback):

Clinical Faculty Signature---:::::;=--------

Q
Student Signature_~ ~ """'----"""--
2- - - --

Revised May 2012

.,
-
1

UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

DAILY STUDENT ANECDOTAL NOTE

Student's Name: ~6~S11r. Hiu~e. Date: q/idi/tj

Course&) {ef?f l Semester_ __..,2,..."--___ Assigned unit: 2\-y"'

Number of hours worked on ,unit: IO\-D~

CLINICAL PRECEPTOR:

-g
Above Average Average Below Average NIA
Motivation to Learn
Patient Assessment
Skills
Safety
Documentation
Professionalism

Comments:

Q,'o W;;..s ~J. ' 1 ~ w.\p~J\ ~J.

(_~ Ao \.£G-<"n\
Preceptor Name: _ _ _M--'-'o=\\_..,,y4-~\o.._\""~....:~c...:.v...:..:~'-y_'---------------
(Please Print) 1 'A l
LA
· =::....:....:~_'_________
Preceptor Signature: -----.,~1ov~~~><--~-~.:9,,.,._~
... {_ _

STUDENT EVALUATION OF PRECEPTOR:

Check all that apply Average Below Average

Knowledgeable
Encouraged learning
Supportive
Acts as role model
Professionalism

Comments:

CLINICAL FACULTY:

~ i s a g r e e with evaluations.

Comments (including preceptor feedback):

Revised M av 201)
 1

UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

DAILY STUDENT ANECDOTAL NOTE

Student's Name: Lbl\-1-S"n rf<Jci Date: lo,4/2-:/:

Course Md fHJ!C I Semester Z.,. Assigned unit: (CcT5
Number of hours worked on unit:

CLINICAL PRECEPTOR:
Above Av~rage Average NIA
Motivation to Learn
Patient Assessment
Skills
Safety
Documentation
Professionalism

Preceptor Name: ---lr-4---¥-::i.-=~:.........i.,._;:!..~__.t.~u...,r__~l-'L::,,!_- - - - - - -

(Please Print)
Preceptor Signature: -----,::-,SZ-:'---0.--'=::::_- ~ ~ ~_.::,,../_---- - - - - - -- -

STUDENT EVALUATION OF PRECEPTOR:

Check all that apply Average Below Average

Knowledgeable
Encouraged learning
Supportive
Acts as role model
Professionalism

Comments:

Comments (including preceptor feedback):

CH•k•I Facolty SI"'- ~~

6,~ ~=---------
Student Signature_ ~ ~

Revised May 2012

 UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING

DAILY STUDENT ANECDOTAL NOTE

Student's Name:1,.,&'4.w, /-'/q)fo, Date: l~/Jz/lj

Course {kJ. ~e J Semester_ _Z...___ Assigned unit: 5N

Number of hours worked on unit: -l-L-
CLINICAL PRECEPTOR:
N/A
Motivation to Learn
Patient Assessment
Skills
Safety
Documentation
Professionalism

STUDENT EVALUATION OF PRECEPTOR:

Check all that apply Average Below Average

Knowledgea ble
Encouraged learning
Supportive
Acts as role model
Professionalism

Comments:

8 ;,•gm
CLINICAL FACUL TY:

wHh mlo,fon,.

Comments (including preceptor feedback):

Clioieol Foeulty Sigo,tn,,~

Student Signature_ _~ ~!".:

Revised May 2012

 1

UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

DAILY STUDENT ANECDOTAL NOTE

Student's Name:
&6t'n5'<9 n Ht1Y-et Date: r I/z/ (1-
Course f-te.J. )wsu
~-
Jr Semester- - - - , ~ - , = - . - - - Ass1gne
· d um·t: c : ~>,no/
F ._1
Number of hours worked on unit: __lb
CLINICAL PRECEPTOR:
Above ADvvee.r.{ge Aveirage Below ABverage NIA
Motivation to Learn
Patient Assessment D
Skills O 0 0
Documentation W D D
-~
Professionalism D D _ - ,1 · Ob
- o.+ - b' Rc:b- so" o)ld fY'vl--hpli \'J •,;, ~ •
Comments: H a..<d wor}::"f.r~ _.0i1 o. q~ -·, € I~ blood. e:,I u,ps.l ,o..-Ad
«"'cL.J'c fol~t-t MOt-i_f d,'J'ff'T •~'- .P :L{j,~ c.£()-+raJ hr\~ , ar,d
hV<\qJ ¼utu\S~ ..5~ro...-,;.~ 1 sn. . a wirYJ ,n 1

or-f o..cc..,..'i. ~5

PreeeptorName:
~~::;t!~:~nature ~ - fl
{<,n
Oft
STUDENT EVALUATION OF PRECEPTOR:

Check all that apply Abov~erage Average Below Average

Knowledgeable
Encouraged learning
Supportive
Acts as role model
Professionalism
I
w
Comments:
;[ lewneJ {o / Y\t,(ch c,..,,I K {}Lt,,.,~H-e.,, fJ..e f/.,e;,LllLJ 6ec@rv-e or ~er.~

CLINICAL FACULTY:

eisagree with evaluations.

Comments (including preceptor feedback):

Revised May 2012

-- 1

l UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

DAILY STUDENT ANECDOTAL NOTE

Student's Name: ~(W) t4/)1'1 Date: // /lll '1-:

Course f1.e) #i,t,ye If,, Semester JI}; Assigned unit: 3W
Number of hours worked on unit: --1..1:_
CLINICAL PRECEPTOR:
Above Average Average Below Average NIA
Motivation to Learn
Patient Assessment
Skills
Safety i
Documentation
Professionalism fB;
Comments:

Preceptor Name,
(Please Print)
Preceptor Signatu:
/i ut~ - , ,

STUDENT EVALUATION OF PRECEPTOR:

Check all that apply Above~rage Average Below Average

Knowledgeable

f
Encouraged learning
Supportive
Acts as role model
Professionalism

tuv/..~

CLINICAL FACULTY:

Bisagree with evaluations.

Comments (including preceptor feedback):

Clinical Faculty Signature_ _ _ _ _ _ _ _ __

Student Signature_ _ _ _ _ _ _ _ _ _ __

Revised May 2012

 1

UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

DAILY STUDENT ANECDOTAL NOTE

Student's Name: ~fr-:lk/1: MffeJ Date: /r /-

I/ /r L{
Course reJ.,~ Semester :IfJ2- Assigned unit: E/Z.
Number of hours worked on unit: / '2-

CLINICAL PRECEPTOR:

rf
AboveA~e Average Below Average NIA
Motivation to Learn
Patient Assessment
Skills
Safety
Documentation
Professionalism .ff
Comments:
ClJ._w c,j 8 \J.)1 I \ •"_) 10 I. UA~v-, •
1
IV' v<. a.nc,l
wu W'I<>"! (A_ ~""<-cvt e..Vl___ k.)\.,VS-C • Pss~py~t,+- & 1H~
Preceptor Name: /'YbJ6 ·SS~ ,{,("l'-._
(Please Print)
Preceptor Signature: ---'-~- -j;;-~c?'=:::::(~?-
..:::...._ _ _ _ _ _ _ _ _ _ __

STUDENT EVALUATION OF PRECEPTOR:

Check all that apply Average Below Average

Knowledgeable
Encouraged learning
Supportive
Acts as role model
Professionalism

Comments:

Comments (including preceptor feedback):

Clinical Faculty Signature

Sludo"I s ;gn,iun ~ - =-......----,,£...-__

Revised May 2012

 1

UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

DAILY STUDENT ANECDOTAL NOTE

Student's Name: ~bi\,$410 l'.ft}~ J..f1.i.J!j____

Date:

Course tfll/.-Wlb1- L Semester__"(.:....-_ _ _ _ Assigned unit: t-"k CV

Number of hours worked on unit: _¼Z__

CLINICAL PRECEPTOR:
Average Bel<H'i AveR'age N/A
Motivation to Learn
Patient Assessment
Skills D
Safety
Documentation D
Professionalism
o t wJJL I

Preceptor Name:
\IV~~!/
(Please Print)
Preceptor Signature:
-~,L.!..__~r---=====----- - -
STUDENT EVALUATION PRECEPTOR:

Check all that apply Above~rage Average Below Average

Knowledgeable
Encouraged learning
Supportive i
Acts as role model
Professionalism f
Comments:

CLINICAL FACULTY:

Bisagree with evaluations.

Comments (including preceptor feedback):

Clinical Faculty Signature

St,dent Signat~:::::::::=
=::;~==-:::;c=::::;
7;::;==---

Revised May 2012

 1

UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

DAILY STUDENT ANECDOTAL NOTE

Student's Name: Ul'r:~ &,~ Date:

/vv!.., '1'-M1 Semester vf

Course
'!'° - Assigned unit:
t'. 1() - ) !10 1~,1- c.,._p
Number of hours worked on unit: ___i__.c / = 'l
CLINICAL PRECEPTOR:
Average Below Average NIA
Motivation to Learn
Patient Assessment
Skills
Safety
Documentation
Professionalism

vJ a& llniaz.11113 tmemel! helvfuI, 11-rJOVl\1"~~b1C- ti l'ld gl~'l;s

wll\M~ -11) ltt,1rn llYla hel(J- Otlv ptffi-cntJ \OVt"d him\_
Preceptor Name:
(Please Print)
-1\J
[(~nu\
f\ f/'\m
Joto
Vltf"-'-'-.-----------------
Preceptor Signature\/r,U~_..J....

STUDENT EVALUATION OF PRECEPTOR:

Check all that apply Average Below Average

Knowledgeable
Encouraged learning
Supportive
Acts as role model
Professionalism

CLINICAL FACULTY:

e i s a g r e e with evaluations.

Comments (including preceptor feedback):

Clinical Faculty Signature- - - - - - - - -

Srud,ntS;gn,ru~

Revised May 2012

 1

UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

DAILY STUDENT ANECDOTAL NOTE

Student's Name: IZ,Qb~,.., t'f;'tt, Date: I /Z-2/ 1'i

Course NlA. Lf'111 Semester_ _Y-'---___ Assigned unit: J-1l3

Number of hours worked on unit: - -

CLINICAL PRECEPTOR:
AboveA ge Average Below Average N/A
Motivation to Learn 0
Patient Assessment
Skills
Safety
l0
Documentation 0"
Professionalism

STUDENT EVALUATION OF PRECEPTOR:

Check all that a(!(!ll'. Above[0jrage Average Below Average

Knowledgeable
Encouraged learning
Supportive
Acts as role model
Professionalism

Comments:
t
- 1- Jr/
fj" l/1'CC,~
- r e ~ t-5ee,,Jlr;,,-, fryle5

CLINICAL FACULTY:

Agree/Disagree with evaluations.

Comments (including (!receptor feedback):

Clinical Faculty Signature~.---~ ----=-......-----

St,d,ot s;gn,ru,~

Revised May 2012

 l Nl\'il:RITTY or SOUTH ft..ORll}A
COLLEGE or Nlflt.~NG

DAILY S'fl'DENT ANECDOTAL NOTE

.. t/ 1/ 1f

CLINICAL PRECEPTOR:
A'-~A NIA
Moth-atioll Lean.
Patient A ~ t : l l t
Sl..ills
Safety
Documenbtioll
B
Professionalism

Preceptor N2me~
(P~se Print)
Preceptor i,gnahlre: J ...JM~0~,:::_1,x.~~..,t_!:::!_':::L__ _ _ _ _ __

Check all dlat apply ~wA.nrage

Knowtedgeabl~
E11coaraged lean1in:g D
Supportive
Am as role 111odel 0
Professio•alisln

CORllftellts:

CLINICAL FACULTY~

~ i s . ~ 'Mtll ~,.....

Revised May 201 2

 UNIVl~RSITY OF SOUTH FLOIUJ)A
COLLEGI~ OF NURSIN(;

DAILY STUDF:N'l' ANECDOTAL NOTE

Studcnt'11 Numc: ~b~f.t, M:(),1'1 Oate: 1,/::Z.,1,/i I

Counc Ml/.... tfti[-4-L- Scmc11tcr_ '-(
-+-_ _ _ _ AHll(ned unit: J{/C,,rJ
Number of houn worked on unit: _,S_
CLINICAL PRECl<:PTOR:
Above A@;v,e Avera,ie Heh>w Average N/A
Motivation to Learn
Patient Assessment
Sklll11
Safety
Documentation
Professionalism
f
Comments:

Preceptor Name:
(Please Print)
Chr,
//
~fl.z
/ .--
k Uno r r
__- -=:.: : ~
Preceptor Signature: _ J_c;___:.,'A::d,:_

STUDENT EVALUATION OF PRECEPTOR:

: t:'.2-
-
~s:::::::-:...,==:------------

Check all that apply Average Below Average

Knowledgeable
Encouraged learning
Supportive
Acts as role model
Professionalism

Comments:
- yt'J-rsf J •
-P1..._t/' ~ , - ..,,..,, ne ,.,.,.'!:.c
- fO rk-ed'-1 - f-l!IK
- t1NAJ- r--tr'K f"t'lf /f-uJ~ ~l)7JV f'"',ri(
CLINICAL FACULTY:

eagree with evaluations,

Comments (including preceptor feedback):

C linical Faculty Signature_ __ _ _ _ _ __

Student lgnatu ~

Revised May 2012

 1

UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

DAILY STUDENT ANECDOTAL NOTE

Student's Name: 14>~/h.;t>'I"\ f1e)/t1 ,j Jt1 /i f

Date:

Course IV\/1-.. lf'16'1-l- Semester_ _~....___ _ _ Assigned unit: fq V

Number of hours worked on unit: (p:~()' 3: W
CLINICAL PRECEPTOR:
Above Average Average Below Average N/A
Motivation to Learn
Patient Assessment
Skills
Safety
Documentation (3-""
Professionalism

Comm~~Mct1 lS a.¥7 &~ ~ . ~-

~,('·i,dt·~ cRt,.v--~, l(I pc,jttnl ~ _ , J ~ ~
/-It, htif µ.l().,t.U!I O<fl<./rm,nf cJ Jt.i'lll a.+-10(, f.Xt.Mt'Lt..e>{ ~ - · · ~ . ·
Preceptor Name: J V\h' ~Ct"\
(Please Print)
Preceptor Signature:
-ii"-+-------""'-'--=---------------
STUDENT EVALUATION OF PRECEPTOR:

Check all that apply Average Below Average

Knowledgeable
Encouraged learning
Supportive
Acts as role model
Professionalism

Comments:

CLINICAL FACULTY:

e,••g,eewuh ..••••••••·
Comments (including preceptor feedback):

Clinical Faculty Sig~

Student Slgnature_~-,,,<,~,.,:;.,s;~::=:.__
_ _ _ _ __

Revised May 201 2

 1

UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

DAILY STUDENT ANECDOTAL NOTE

Student's Name: /1.cb~"'1 f-'<-e;t-0 Date: Z.

7
ff// J::
J
Course Ml~ '1'U'J.-L- Semester__Jj.._____ Assigned unit: lfL 'Jr,! f-/tPt?r-

Number of hours worked on unit:

CLINICAL PRECEPTOR:
Average Below Average NIA
Motivation to Learn
Patient Assessment
Abo••1 •••
Skills
Safety
Documentation
Professionalism
"?SJ.
Comments:

PreceptorName: :Jgssiccx..
(Please Print) Q L~o
c~~L,()
Preceptor Signature: ---1'~ -""'~"'--""-
~ ~ ___.,_L--=-----=----A----- -- - - - -

STUDENT EVALUATION OF PRECEPTOR:

Check all that apply Average Below Average

Knowledgeable
Encouraged learning
Supportive
Acts as role model
Professionalism

Comments:

CLINICAL FACULTY:

Bisagree with evaluations.

Comments (including preceptor feedback):

Stodent s;gnat"" ;,#'--#~_

Clinical Faculty Signature
~r--2- - - -

Revised May 2012

 1

UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING

DAILY STUDENT ANECDOTAL NOTE

Student's Name: M~ Date: Z;/t?/t S:'

Course /vvg_ 1'(1([,fL Semester_ _._q_"'_ _ _ Assigned unit: .HlJ '1"' f-loor
Number of hours worked on unit: _ _

CLINICAL PRECEPTOR:
Average Below Average NIA
Motivation to Learn
Patient Assessment
Skills
Safety
Documentation
Professionalism

Comments:

PreceptorName: ~O cl\od
=========-- -----------
(Please Print)
Preceptor Signatur .

STUDENT EVALUATION OF PRECEPTOR:

Check all that al!l!ll'. Abov~erage Average Below Average

t
Knowledgeable
Encouraged learning
Supportive
Acts as role model
Professionalism

Comments:
..;alfaE=. · 1-\ (,o=Co C\cil"'-r f r,J,µ-e,5 {.,...ff-.r>e~fcJ) rni.,c,Hce
.,,-0 I vt;,.l >~n.1 C, o" f'eW ~o<Y'1t~

CLINICAL FACULTY:

~/Disagree with evaluations.

Comments (including l!recel!tor feedback):

Clinical Faculty Signature_ _ __ _ __ _ _

Student Signature
/
Revised May 2012
 UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING

DAILY STUDENT ANECDOTAL NOTE

· Student' s Name: IZ,A1/hf,i,.n H~,'k, Date: /1 '6

2,,,/J J
Course .fvl/1... 4'{ kfl Semester '1 I""\ Assigned unit: &1 {;I/Mevf 5v17
Number of hours worked on unit:

CLINICAL PRECEPTOR:
Aboveiage Average Below Average NIA
Motivation to Learn
Patient Assessment
Skills
Safety
Documentation
Professionalism

Comments:
;
.vi.. fu_,.;../-! ,. ·- .I ..,, l'ltJt/ Y/rl/A::r / Jv {IV/tLN
1_
;?.Dbn1J~ n VVlf J1¥ftt,--r /)J 17 " /»t, vv,14 Ju 'I!.1.. 7' J / '- I
N~cud OIt/. t1 ~~-t w, fJ/1 vw d Wt is pt "-0tJ~ T K-1->f rvi.td I 1-U tt
A

·
MY ~-e e-( P:,. fti_A/f-S' N.-ef_ d J vUtc/ S i,iwJ.pt/ t 11, +114 -r,tlt .
P,ecepto,Name: ~,/
(Please Print)
Preceptor Signature: ~ £
STUDENT EVALUATION OF PRECEPTOR:

Check all that apply Abovee g e Average Below Average

Knowledgeable
Encouraged learning
Supportive
Acts as role model
Professionalism

Comments:
-~ t'"'J
-!fb M,-r__ fed~
-C~~/ ~"'6 lf'sl:J
CLINICAL FACULTY:

§isagree with evaluations.

Comments (including preceptor feedback):

Clinical Faculty Signature_ _ _ _ _ _ _ __

' '".' "' s;gn""" p24fr::z-

Revised May 201 2
-
UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING

DAILY STUDENT ANECDOTAL NOTE

Student's Name: Lbf'Mo,, /'¾¥ 01 Date: .2/11 / I 8

I

Course NUf... q'1 £1. L- Semester/,/ r'-1

-- - - -- Assigned unit: l- <W. 'O
Number of hours worked on unit: _j_
CLINICAL PRECEPTOR:
Above A erage Average Below Average N/A
Motivation to Learn
Patient Assessment
Skills
Safety
Documentation
Professionalism .
du~ n::,ht ,½ -Iv ~-e.lp 1
Preceptor Name: _ _..,.=-s.=J~ ..__1-+.Lf-1...<CL-l-- - - - - - -- -- -- - -
(Please Print)
Preceptor Signature: - -~~..!:::'.l&<:;b-__l,,,!!,6~:::.!.....==-- - -- - - - - - -

STUDENT EVALUATION OF PRECEPTOR:

Check all that al!l!ll'. Above~erage Average Below Average

r
Knowledgeable
Encouraged learning
Supportive
Acts as role model
Professionalism

Comments:
v-A'mt ss \l1lj (

CLINICAL FACULTY:

eisagree with evaluations.

Comments (including j!recej!tor feedback):

Clinical Faculty Signature?'"""=r- - = =~ - - -

St•denl s;g"'I""~

Revised May 201 2