Pediatric Advanced Cardiac Imaging Fellowship Evaluation Form
Name of Applicant
*
First Name
Last Name
Relationship to Applicant
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Program Director
Dept/Division Chair
Advisor
Clinical Preceptor
Research Preceptor
Other
If "Other" please specify
Compared to other pediatric cardiology fellows at a similar level going on to 4th year fellowships that you have supervised and have been the preceptor over, how would you rate this applicant? Please check the boxes that most closely represent your opinion of the applicant.
Below Average
(Lower 50%)
Average
(Upper 50%)
Very Good
(Upper 20%)
Outstanding
(Upper 10%)
Superlative
(Upper 5%)
Unable to Judge
Comment Below
Overall Clinical Ability
Interpersonal Skills
Intellectual Skills
Potential as an Academic Pediatric Cardiologist
Potential for Research
Leadership
Teaching/mentoring of junior trainees
Technical Imaging Skills
Interpretive Imaging Skills
Additional Comments
Name (Print)
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First Name
Last Name
Title
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Signature
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