King Saud bin Abdulaziz University

for Health Sciences

Form UCE 10:
COLLEGE OF MEDICINE
CLINICAL AFFAIRS Clinical Attachment Performance Feedback
(to be used in clinical rotations with daily activities)

0 Not achieved
Name: 1 Poor
2 Below Average
Block: Batch: Group: 3 Borderline
Covered Period: DD / MM /20____ to DD Clinical Sub-group: 4 Satisfactory
/ MM / 20____ Rotation:_______________

Clinical Supervisor or
Day Case short description Designee’s name,
signature & comment
Day 1
S M T W Th

Date: DD / MM /20__

Day 2
S M T W Th
Date: DD / MM /20__

Day 3
S M T W Th

Date: DD / MM /20__

Day 4
S M T W Th

Date: DD / MM /20__

Day 5
S M T W Th

Date: DD / MM /20__

Clinical Supervisor’s
Name, signature &
comment:
DD / MM /20___
Student’s comment:
DD / MM /20___
Formative feedback Given Not Given Clinical Supervisor’s Name & Signature

Instruction to the tutor: Please insert in the assessment box immediately after the session
or send to Clinical Affairs office (Mail code 1418, Phone # 84-94008)