STUDENT EVALUATION OF PRECEPTOR
Preceptor: ______
(Last) (First) (Middle)
Student: ______
(Last) (First) (Middle)
RUID: ______
Agency Name: ______
Address:______
______
______
______
Agency Phone Number: ______
Course Name: ______
Clinical Specialty: ______
Semester and Year: ______/ ______
Faculty: ______
Directions: The student should complete this form by the end of the semester. The evaluation results should be returned to the faculty member responsible for the course.
ATTENTION STUDENTS
Please supply the number of clinical hours and your preceptor(s) worked with you this semester. This information is necessary since many preceptors are now requesting documentation of the house they served as preceptors for their re-certification.
PRECEPTOR #1: ______
Name (please print)
HOURS OF PRECEPTING THIS SEMESTER: ______
PRECEPTOR #2: ______
Name (please print)
HOURS OF PRECEPTING THIS SEMESTER: ______
- Please place a check mark to indicate whether or not the preceptor performed each of the following activities. If the activity did not apply, place a check mark in the NA (Not applicable) column. Space is provided for your comments.
YES / NO / N/A / COMMENTS
1. Introduced student(s) to the staff and toured the clinical agency
2. Explained agency policies and procedures to student(s)
3. Assisted student(s) to identify goals / needs for each clinical experience
4. Scheduled time for mid-term and final evaluation conferences
5. Modeled high standards of patient / client care.
6. Provided opportunities for the student to observe / participate in the main functions of the advanced practice role
7. Demonstrated mastery of new knowledge and developments in the advanced practice role
8. Had a positive attitude toward student(s)
9. Maintained effective relationships with staff to facilitate student(s) clinical experiences
10. Encouraged student(s) to assume increasing responsibility during the semester.
11. Met with student(s) on a regularly scheduled basis
12. Evaluated student(s) progress during mid-term and final conferences
- Using the following scale, please place a check mark to indicate how frequently during the semester the preceptor performed each of the activities listed below. Space is provided for your comments.
Frequently / Usually / Seldom / Never / Rarely / COMMENTS
1. Arranged learning experiences for student(s) to meet goals for each clinical
2 Was comfortable sharing expertise with student(s)
3. Was available to student(s)
4. Provided assistance to student(s) when needed.
5. Selected instructional methods to encourage student learning.
6. Assisted student(s) to find additional learning resources when appropriate
7. Gave constructive feedback to student(s) regarding the exent to which identified goals / needs for each clinical were met.
8. Encouraged suggestions from the student(s)
9. Provided feedback regarding critical thinking and skill development of student(s)
10. Made fair and impartial judgements about performance of students
- Would you recommend this preceptor for the future? (circle) YES / NO
- Please indicate your reason for your answer to question #3 in the space provided below:
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