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HPS Placement Evaluation
.
Name
Last four digits of SSN
Date of Birth
Discipline
APN/CNS
CRNA
Dental
Health Administration
Medicine
OT
Other
PA
Pharmacy
PT
Public Health
RN or LPN
Social Work
Speech Pathology
If Other, please specify
Rotation Course
Placement Start
Placement End
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
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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