HPS Placement Evaluation

Name

Last four digits of SSN

Date of Birth

Discipline

If Other, please specify

Rotation Course

Placement Start

Placement End

Project Title

1 = Poor, 2 = Marginal, 3 = Competent, 4 = Superior, 5 = Exeptional

Preceptor 1 Name

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 trainingv.

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

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

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