Reporting form of the practice training

MINISTRY OF EDUCATION AND SCIENCE OF RUSSIAN FEDERATION

Federal State Autonomous Educational Institution of Higher Education
«V. I. VERNADSKY CRIMEAN FEDERAL UNIVERSITY»
Medical Academy named after S. I. Georgievsky (structural subdivision).

INTERSHIP JOURNAL

Name of practice: _____________________________________________________

student __________________________________________________________
(full name)

faculty ________________________________ course group ____________

form of education full-time

direction of training (specialty) ___________________________________

(code, name)

orientation (profile) _______________________________________________

place of practice ________________________________________________________

(city, urban village)

specialized organization ________________________________________________

______________________________________________________________________

duration of practice: from____________________ till ____________________20___

Chiefs of Practice from specialized organization:

general ________________________________________________________________
(position, full name)

immediate______________________________________________________________
(position, full name)

Practice Chief of the Medical Academy:

______________________________________________________________________
(position, department, full name)

1. Work schedule of Practice

 weeks of Practice
# Name of work
1 2 3 n

Practice Chief’s signature:

from the Medical Academy ___________________________

from the specialized organization ___________________________

1. A list of treatment-and-consultation work done during the practical training

# Date Name of work Marking Chief’s
 signature of
performance specialized
of work organization
1 2 3 4 5

1. Review of the trainee

(Specialized organization)
 ______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Chief’s signature of specialized organization __________________________________

4. Practice Chief’s conclusion of the Medical Academy about student’s work

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_____________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Practice Chief’s signature of the Medical Academy __________________

«___» _____________ 2017

Grade for practice __________________________

Practice Chief’s signature of the Medical Academy __________________

Information for filling lines: «The direction of training (specialty) »

List of specialty code:

- 31.05.01 General Medicine

- 31.05.02 Pediatrics

- 31.05.03 Dentistry

- 33.05.01 Pharmacy