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HPS Placement Evaluation
Name
*
First
Last
Last four digists of SSN
Date of Birth
*
Discipline
APN/CNS
CRNA
Dental
Health Administration
Medicine
OT
PA
Pharmacy
PT
Public Health
RN or LPN
Social Work
Speech Pathology
Other
If Other, please specify
Rotation Course
*
Placement Start
*
Placement End
*
Number of patient contacts
*
Project Title
Preceptor 1
1 = Poor, 2 = Marginal, 3 = Competent, 4 = Superior, 5 = Exeptional
Preceptor 1 Name
First
Last
Preceptor Discipline
1. Demonstrated a genuine interest in me.
1
2
3
4
5
2. Answered my questions clearly.
1
2
3
4
5
3. Allowed me to assume increasing levels of responsibility.
1
2
3
4
5
4. Tailored teaching to my needs.
1
2
3
4
5
5. Provided me with frequent feedback and evaluation.
1
2
3
4
5
6. Was knowledgeable of the course requirements for this clinical experience from the syllabus.
1
2
3
4
5
Comments
Site Evaluation
Site Name
1. Clinical site offered a range of patients with different presenting diagnoses.
1
2
3
4
5
2. Clinical site provided care to patients of different areas.
1
2
3
4
5
3. Clinical site accepted and incorporated me into daily activities.
1
2
3
4
5
4. Clinical site offered experiences that were appropriate for my discipline and level of training.
1
2
3
4
5
5. Clinical site was well suited as a training site for health professions students.
1
2
3
4
5
comments
AHEC Evaluation
1. Provided sufficient information to orient me to the community.
1
2
3
4
5
2. Provided a sufficient number of visits to support me while on this rotation.
1
2
3
4
5
3. Provided resources (i.e. technology, library services, project resources) to help me meet the academic requirements for this rotation.
1
2
3
4
5
4. AHEC student coordinator was accessible and helpful when needed.
1
2
3
4
5
5. Housing was safe and within a reasonable distance from my clinical site.
1
2
3
4
5
What went well?
What could be improved?
Comments
Preceptor 2 (if applicable)
Preceptor 2 Name
First
Last
Preceptor Discipline
1. Demonstrated a genuine interest in me.
1
2
3
4
5
2. Answered my questions clearly.
1
2
3
4
5
3. Allowed me to assume increasing levels of responsibility.
1
2
3
4
5
4. Tailored teaching to my needs.
1
2
3
4
5
5. Provided me with frequent feedback and evaluation.
1
2
3
4
5
6. Was knowledgeable of the course requirements for this clinical experience from the syllabus.
1
2
3
4
5
Comments
Preceptor 3 (if applicable)
Preceptor 3 Name
First
Last
Preceptor Discipline
1. Demonstrated a genuine interest in me.
1
2
3
4
5
2. Answered my questions clearly.
1
2
3
4
5
3. Allowed me to assume increasing levels of responsibility.
1
2
3
4
5
4. Tailored teaching to my needs.
1
2
3
4
5
5. Provided me with frequent feedback and evaluation.
1
2
3
4
5
6. Was knowledgeable of the course requirements for this clinical experience from the syllabus.
1
2
3
4
5
Comments
Forms Bank
Certificate and Transcript Request Form
Video Rental Form
HPC Practicing Professionals and Former Students Update Form
Individual Consortium Membership Application
E-Club Form
Housing Request Form
HPS Placement Evaluation
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