Student Evaluation Student Portion II

First Name*

Last Name*

Life Number*

Program

Student MSSM Email Address*

example@example.com

Elective Type*

Clinical Elective (Empower)Clinical Tailor MadeResearch/ Non-Clinical Tailor Made/ Non-Clinical EmpowerAway Elective

Name of Elective*

Elective Code (EXAMPLE: MED 2335- check the approved elective form for this)*

Location

Dates

The date range above is:*

CorrectIncorrect

Start Date*

Date

Completion Date*

Date

Research/ Non Clinical Evaluation Criteria
PASS	FAIL
UNDERSTANDING
Demonstrated understanding of concepts or tasks to be performed	Could not provide basic understanding of concepts or tasks to be performed
Student demonstrates understanding of advanced concepts	Student demonstrates basic understanding of concepts
PROFESSIONALISM
Arrived on time and prepared Ready to receive feedback and suggestions Integrated feedback Considerate of others' time and value to the team	Arrived late regularly; unscheduled absences Inappropriate conduct
ABILITY
Able to perform task/work outlined with minimal supervision Demonstrated knowledge or interpretation of tasks	Unable to perform tasks/work outlined for the elective
INITIATIVE & RESPONSIBILITY
Appropriate with some supervision to move forward Completed tasks when assigned by team Took ownership and direction of the work required	Low level and unable to move forward
TEAMWORK & COMMUNICATION
Worked well with others Effective member of the team Kept team informed on progress or any questions or challenges	Poor teamwork, poor collaboration Poor communication (oral or written)

Clinical Elective & Clinical Tailor Made Evaluation Criteria
Preparation and Participation
Honor	Pass	Fail
Student arrives prepared to participate	Student arrives prepared to participate	Student generally arrives unprepared to participate
Knowledge of Medical Concepts
Honor	Pass	Fail
Student demonstrates understanding of advanced concepts	Student demonstrates basic understanding of concepts	Student cannot provide basic understanding of concepts
Application and Communication of Medical Knowledge to Clinical Care
Honor	Pass	Fail
Shares knowledge with others in clinical setting	Demonstrates knowledge gained without prompting	Unable to demonstrate knowledge gained, even with prompting
Psychomotor Skills
Honor	Pass	Fail
Can perform psychomotor skills relevant to the elective with supervisor available	Can perform psychomotor skills relevant to the elective with supervisor assisting	Arrives late regularly; unscheduled absences
Professionalism
Honor	Pass	Fail
Is proactive and actively engages with team bi-directionally	Completes tasks when assigned by team	Inappropriate Conduct

This is the faculty member who you have worked with during your elective who will be evaluating you. You may only select ONE EVALUATOR PER COURSE. This cannot be a fellow or resident.

Evaluator/ Faculty Full Name*

PrefixFirst NameLast Name

Elective/ Course Director

Evaluator/ Faculty Email*

example@example.com

Fin Elective Title

By submiting this form, you acknowledge that the information provided will be sent to the Evaluator/ Faculty Email for evaluation.

Location Code

Section Code

Crs Type Code

Crs Type

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Elective Evaluation

Student Information

ELECTIVE INFORMATION

Evaluator/ Faculty Information