Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬

Ministry of Health ‫وزارة الصحة‬

King Saud Medical City ‫مدينة الملك سعود الطبية‬
ACADEMIC AFFAIRS ‫إدارة الشؤون األكاديمية‬
STRICTLY CONFIDENTIAL
EVALUATION OF INTERNSHIP ROTATION
Date: ____ / ____ / ________ Department: _____________________ Division: _____________________
Name (in block letters): ___________________________________________________________________________
Name of University: _____________________________________________ University No.: ________________
Date of Rotation: from ____ / ____ / _______ to ____ / ____ /________ Period: ________ Month(s)
Unsatisfactory Borderline Average Above Outstanding
No. A: Academic Qualities Average
1-2 3-4 5-6 7- 8 9 - 10
1. General medical knowledge
History taking Ability and skills in
2.
physical examination
Ability to diagnose and manage
3.
problems
4. Quality of written records
5. Quality of oral presentation
No. B: Personal Qualities
Character, behavior and relation with
1.
patients and their relatives
2. Responsibilities and self-confidence
Relating effectively to colleagues and
3.
other medical personnel
4. Attendance and punctuality
5. Ethics
Grand Total Score
Notes: the Intern should score a pass mark in each section separately.
NUMERICAL GRADE: Assign a numerical mark as per the table below:
Grade Unsatisfactory (Fail) Satisfactory (Pass) Good Very Good Excellent
Mark < 60 60 - <70 70 - <80 80 - <90 < 90
In the case of failure or a poor assessment the Department MUST provide a description of the Intern problem and suggest the
remedial action(s) required.

Was the assessment based upon discussion with other Consulting Staff?  Yes  No
Was the assessment based upon discussion with other Junior Staff?  Yes  No

Supervisor of Rotation: ___________________________________ Signature: ___________________

Intern Coordinator: ___________________________________ Signature: ___________________

Chairman of Department: ___________________________________ Signature: ___________________