STUDENT NAME: _ ______________________SITE: __ ________________________

EVALUATOR: _ ________________________________DATE: ________________

Student Self-Assessment Faculty Assessment

What am I doing well? What is the student doing well?
1. 1.
2. 2.
3. 3.

Where can I improve? Where can the student improve?

1. 1.
2. 2.
3. 3.
Faculty Assessment Something to Doing Well A Particular Cannot Assess
of Competencies: Focus On Strength
Medical Knowledge
Patient Care
Interpersonal &
Communication Skills
Practice Based
Learning and
Improvement
Systems-based Practice
Professionalism

Student must bring Meditrek print out that shows that at least half Mandatory Encounters have
been completed.

¨ I have reviewed the student’s Meditrek log.

 Deficiencies/gaps noted:
______________________________________________________________
Student Plan/Action Items in Response to Above Feedback:
1.
2.
3.
Evaluator Signature: ___________________________________ Date: __________________
Student Signature: ____________________________________ Date: __________________