_ Signature:
Educational Institution:
Program:
Department assignment:
Date
:
8
Appendix G Student/Faculty Evaluation (Circle One) Name of School Affiliation:
Type of Student:
Nursing
PT
Speech
Respiratory
Pharmacy
Other:
Facility:
Unit:
Dates: From:
T0:
We would like you to evaluate your time spent here in our facility during your clinical
rotation. Your input is very important as we continuously strive to improve and enhance the
quality of services we provide. Please share your thoughts and suggestions by circling your
rating of each item.
Please return this completed evaluation to your clinical area Unit Manager or Education Services at the facility of your clinical experience. Thank you for your feedback. Rating Scale N/A = Not Applicable
1 = Poor (Needs Major Revisions)
2= Fair (Revision Needed)
3= Good (Could Use Slight Revisions)
4= Excellent (No Change Suggested
Learning opportunities were available to help me meet my
clinical objectives.
4
3
2
1
N/A
Resources were available to assist me with my learning
needs.
4
3
2
1
N/A
Staff displayed professional and caring behaviors.
4
3
2
1
N/A
Opportunities were available to collaborate with different
types of health care providers.
4
3
2
1
N/A
Staff members were open to questions and assisted me with
problems as needed.
4
3
2
1
N/A
Patient care supplies were available as needed.
4
3
2
1
N/A
Equipment was in good working order.
4
3
2
1
N/A
How would you rate the care here if you were a patient?
4
3
2
1
N/A
If you marked a 2 or less, what could be done to improve this clinical experience? Please list
any staff names you would like to recognize
