WINDSOR UNIVERSITY SCHOOL OF MEDICINE

Campus: Bird Rock, Basseterre, St. Kitts Phone: 869-466-1 !, "a#: 869-46$-!$9% &mai':(usadmin)*indsor.edu( +e,:(***.*indsor.edu( -ur t: .S/ 0n1ormation -11ice : 6212 Monee Manhattan, Rd Monee Illinois 60449

ROTATION EVALUATION FORM Send in your evaluation by completing the blocks below and mail to: Windsor information office,
6212 Monee Manhattan, Rd Monee Illinois 60449

Students last Name:

M.I.

Students First Name

Hospital/Site

RO ! "O#: Start $ate: %nd $ate: #o of Weeks:

PRECEPTOR: Please, menti n stren!t"s and #ea$nesses as #ell as areas % r im&r 'ement (el #. Als , &lease %ill ut t"is e'aluati n % rm n re'erse side.

Primar) Pre*e&t r &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&+ate&&&&&&&&&&&&&&&& Print Name

Si!nature

Ot"er E'aluat rs

Attest t"at I "a'e re'ie#ed t"is e'aluati n #it" t"e &re*e&t r . Student Signature &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& RO ! "O#: &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& #!'% O( H% S )$%# &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& $ate: &&&&&&&&&&&&&&&&

N te:

Please *ir*le a&&r &riate num(er. E'aluate in * nte,t % students le'el % trainin!. I% ) u *ann t e'aluate, &lease mar$ N-A in t"e EVALUATION CRITERIA ( ,.
Outstanding /0 12 13 Above Average 14 15 16 17 Average 18 1/ 11 10 2 3 ,onsistently Satisfactory Below Average 4 5 6 7 Unsatisfactory 8 / 1

Evaluation Criteria H* +/,!S% +R%S%# ! "O# ,omplete,organi-ed, appropriate, differentiates normal and abnormal findings, presents differential/final $. CLIN .U+/EMENT "ndependently uses data to reach diagnosis and management: understands basic principles of the clinical case; 0NO1LE+/E Reads and understands tests and <ournals, able to discuss the %tiology, signs and symptoms, differential diagnosis and management of diseases; "#" ! "=% * $%+%#$!9">" ? Works well with minimal direction: punctual: seeks answers in effective manner follows up independently

,onsistently Superior

Sometimes Superior

9arely !cceptable

,onsistently )nsatisfactory

/0

12

13

14

15

16

17

18 1 / 11 10 2 ,onsistently Satisfactory

4 5 6

,onsistently Superior

Sometimes Superior

9arely !cceptable

,onsistently )nsatisfactory

/0

12

13

14

15

16

17

18 1/ 11 10 2 ,onsistently Satisfactory

4 5 6

,onsistently Superior

Sometimes Superior

9arely !cceptable

,onsistently )nsatisfactory

16

17

18

1/

11 'ost

10 2

,onsistently $ependable

$ependable of ime

)sually $ependable

#ot Often $ependable

,onsistently )ndependable

+RO@R%SS #O %S * ,H!R S !ccurate, organi-ed complete, timely, understands evaluation * 'anagement +! "%# /(!'">? "# %R!, "O# %stablishes rapport shows compassion and professionalism 9!S", S,"%#,%S +R"#,"+>%S $emonstrates relationship of structure and function in diagnosis and applies basic sciences principles H%!> H %!' +!R ","+! "O# !ctive team player demonstrates imitative in terms of patient care

10 ,onsistently Superior

Sometimes Superior

,onsistently Satisfactory

9arely !cceptable

,onsistently )nsatisfactory

10 ,onsistently +rofessional 10 ,onsistently Superior

+rofessional most of ime 2 3

)sually +rofessional

Seldom +rofessional 7 8

)nprofessional * "mmature / 1

Sometimes Superior

,onsistently Satisfactory

9arely !cceptable

,onsistently )nsatisfactory

10 "nspires Others

Auick to =olunteer and !ssist

@enerally Works Well with Others

Seldom Works Well with Others

$oes #ot Work Well with Others

Primar) Pre*e&t r Name 22222222222222222222222222222 Primar) Pre*e&t r Si!nature 2222222222222222222 +ate: 2222222222222222222222 Students Si!nature 2222222222222222222222222