INTERNSHIP ASSESSMENT AND FEEDBACK FORM

Name of Intern Dr ID No

Department Unit:

Head of Department

Internship period From To Days Leave Absent

Extension of posting recommended yes / no

If Yes No of days Extension recommended

PLEASE RATE ON A SCALE OF A, B, C, D

Outstanding(A) , Good(B) , Average(C) Need further training/Extension (D)

RATING SCORE

Scoring may be based on (a) Knowledge (b) Patient Care (c) Procedural Skills(d) Independent care (e)
Communication

Skills (f) System Based Practice (g) Professionalism (h) Life-long Learning

Intern :Dr -------------------------------- signature ----------------- Date:

Unit chief --------------------------------- signature ----------------- Date:

Dr …........................................... has successfully completed / not completed the postings in

…......................................... for the period of …..........................from..........................to …........................

with / without absence of days and has learnt the necessary procedures.

Dr

Head of Department

GOVT GENERAL HOSPITAL KOZHIKKODE

INTERNSHIP ASSESSMENT AND FEEDBACK FORM

Name of Intern Dr ID No

Department Unit:

Head of Department

Internship period From To Days

Leave Absent
Extension Period

PLEASE RATE ON A SCALE OF A, B, C, D

Outstanding(A) , Good(B) , Average(C) Need further training/Extension (D)

RATING SCORE

Scoring may be based on (a) Knowledge (b) Patient Care (c) Procedural Skills(d) Independent care (e)
Communication

Skills (f) System Based Practice (g) Professionalism (h) Life-long Learning

Intern : Dr ------------------------------- - signature Date:

Unit chief --------------------------------- signature Date:

Dr …......................................... .. has successfully completed the postings in

…......................................... for the period of …..........................from..........................to …........................

with /

without absence and has learnt the necessary procedures.

Dr

Head of Department