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Lampiran 3 [PPSP/MD/ELEKTIF_4/CP1/L3]

School of Medical Sciences,


USM Health Campus
Kelantan,16150 Malaysia

To the supervisor
of medical students
from USM, Health Campus

Dear Supervisor,
Thank you very much for supervising our student during her / his elective at your
institution. We would be most grateful if you could fill out the attached
assessment form.
Please kindly hand the student the completed form. The student will bring with
her/ him to the academic office of School of Medical Sciences USM.

Yours sincerely
Elective Secretariat
Academic Office
School of Medical Sciences
USM, Health campus
16150 Kubang Kerian
Kelantan, Malaysia
Phone:609-7676045 / 6046
Fax: 609-7653370
Email: ismaildr@kb.usm.my
reeny@kck.usm.my

ASSESSMENT CLINICAL ELECTIVE FORM


Dear Supervisor
Below are the statements addressing the performance of a student from school of Medical Sciences USM
when working under your supervision.

Name of student:..

Date:

Please kindly circle the number for each statement based on the scale given:
Very good 4

Good 3

Satisfactory 2

The statements
How well the student prepared for the programme conducted under
your supervision with respect to basic science knowledge?

Unsatisfactory - 1
Scale
4

How well the student prepared for the programme conducted under
your supervision with respect to clinical knowledge?

How well the student prepared for the programme conducted under
your supervision with respect to communication skill?

How well the student prepared for the programme conducted under
your supervision with respect to practical skill?

How did the student progress when working under your supervision
with respect to acquisition of relevant knowledge?

How did the student progress when working under your supervision
with respect to participation in department activities?

How did the student progress when working under your supervision
with respect to issues in medical ethics?

How did the student progress when working under your supervision
with respect to punctuality and attendances?

How was the students attitude when interacting with patients, faculty
and colleagues?

What is your overall judgment on the students performance?

Additional comments (if any)


..

Supervisors name:

Signature & official stamp:

Thank you very much for your cooperation.


Fn/elektif/PPSPassessment/nrra/2010