Elective Evaluation Form - College of Medicine
Elective Evaluation Form - College of Medicine
Elective Evaluation Form - College of Medicine
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University <strong>of</strong> Illinois <strong>College</strong> <strong>of</strong> <strong>Medicine</strong> at Urbana-ChampaignOFFICIAL FACULTY EVALUATION FORMOF STUDENT CLERKSHIP PERFORMANCEON CLINICAL ELECTIVESStudent Name:Clerkship Director:Clerkship Name & Number: Clerkship Dates: Today’s Date:Location <strong>of</strong> Clerkship <strong>Elective</strong>:Grade the student on each <strong>of</strong> the listed dimensions using the scale outlined below.O = Outstanding – Student performs at a level observed in only the most outstanding students over theyears. Students who receive this designation will be recognized as those whose absolute performance isconsistently outstanding and who are active, self-directed learners.ADV = Advanced – This designation is reserved for students who are especially pr<strong>of</strong>icient but notconsistently outstanding in knowledge, skill, and performance.PR = Pr<strong>of</strong>icient – Performance may be outstanding at times and is, in general, within the range expectedfor medical students who are progressing satisfactorily. These students function and learn effectively in avariety <strong>of</strong> settings and meet all clerkship requirements.INC = Incomplete – Student has not completed all required clerkship activities due to illness, leave <strong>of</strong>absence, etc. If this grade is assigned, the faculty will describe the activities which remain to be completed.U = Unsatisfactory – This grade is reserved for those individuals who have not met all departmentalrequirements for successful completion <strong>of</strong> the clerkship and further are judged to be beyond remediation.This grade is most likely to be assigned to a student who has completed one or more remediation attemptsunsuccessfully but might also be assigned if clerkship faculty are convinced further efforts to complete theclerkship are not in the best interest <strong>of</strong> the student or the public.<strong>Evaluation</strong>s DimensionsBASIC KNOWLEDGE OF:Pathophysiology, basic mechanisms, and clinical medicine in this discipline.APPROPRIATE USE OF ACADEMIC AND CLINICAL LITERATURE:Independent reading and learning.ABILITY TO PRESENT AND DISCUSS CASES:Clear, succinct, and well organized.CLINICAL SKILLS:Ability to arrive at a reasoned problem list and differential diagnosis, to formulate a treatment plan, and t<strong>of</strong>ollow patient’s progress.INITIATIVE – PERSEVERANCE:Willingness to work hard, to learn, to accept responsibility, and to participate activelyHISTORY AND PHYSICAL EXAMINATION SKILLS:Cogent and complete history, appropriately thorough and complete physical examination using propertechnique and skillDEPENDABILITY – PUNCTUALITY – RELIABILITYPROFESSIONAL RELATIONSHIPS:Attitude toward and respect for peers, physicians, other health team members, patients, and familyCLERKSHIP EXAMINATION (oral and/or written if applicable)GradeOVERALL FINAL GRADE (Please Circle One)Outstanding Advanced Pr<strong>of</strong>icient Incomplete UnsatisfactoryFinal Grades are due in the Student Affairs Office no later than TWO weeks after the end <strong>of</strong> the clerkship. Please alsocomplete the other side <strong>of</strong> this form.
Please comment on the overall performance <strong>of</strong> the student to be included into theMSPE (a.k.a. Dean’s Letter).General Comments On Student Performance:Weaknesses – Recommended Areas To Improve:I have read this report._____________________Signature – Student__________________________Print Student Name__________________________________Signature – Faculty__________________________________Print Faculty NameFinal Grade forms are to be returned to:Julie WyantUniversity <strong>of</strong> Illinois <strong>College</strong> <strong>of</strong> <strong>Medicine</strong> at Urbana-Champaign125 Medical Sciences Building506 South MathewsUrbana, Illinois 61801Phone: 217.333.8146Fax: 217.333.2640