EMERGENCY MEDICINE CLERKSHIP STUDENT EVALUATION FORM

HACKENSACK UNIVERSITY MEDICAL CENTER

STUDENT’S NAME ________________________________ DATE_________________________

Fund of Knowledge
Deficient Developing Pass High Pass Honors (PGY1)

History and Physical Exam Skills

Deficient Developing Pass High Pass Honors (PGY1)

Clinical Reasoning
Deficient Developing Pass High Pass Honors (PGY1)

Procedural Skills
Deficient Developing Pass High Pass Honors (PGY1)

Relationship with patients

Deficient Developing Pass High Pass Honors

Attitude and Professionalism

Deficient Developing Pass High Pass Honors

Overall Performance
Performance Obtains and Consistent Suggests mgmt At/above level of ED
below reports basic interpretation of options. Deep Intern. Manages
expectations and information data. Active knowledge of own patients independently
needs participant in patients
improvement patient care

Comment on the student’s academic performance, strengths

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Comment on the student’s professional behavior, rapport with staff and patients, motivation
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Something the Student Can Improve upon:

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EVALUATOR___________________________________________________________
(Name and Title, Please Type or Print )

Signature________________________________________Date____________________________