Multi-Disciplinary Team Feedback Form

Clinical Pastoral Education

is a Chaplain Intern in Mount Carmel Health System’s Clinical Pastoral Education (CPE) program. This education program is offered by Chaplaincy Services. The program offers clinical training in pastoral care/chaplaincy to people, such as seminarians, clergy, and church lay persons. Because evaluation is an important part of the intern’s learning, I am requesting feedback about the intern as part of the mid-unit assessment. Please be as candid as possible. Feedback helps the intern know how to improve. Comments are helpful if time permits. Thank you for your help and contribution to the intern’s learning.

PLEASE RETURN FORM BY (INTEROFFICE MAIL) TO:

Jill Rasmussen-Baker, Clinical Pastoral Educator

Corporate ServicesCenter (CSC)

1)Estimate frequency of contacts you have had with the intern:

neverfrequent contact

123456

Comments:

2)Please rate your overall level of comfort in relating to the intern:

very uncomfortablevery comfortable

123456

Comments:

3)Please rate your overall level of confidence in the intern's ability to care for patients and family members.

not confident at allvery confident

123456

Comments:

4)Please rate the intern on the professional image he or she projects. This would include such items as clothing/dress, mannerisms, speech and poise.

very poor professional imagevery positive professional image

123456

Comments:

5)How comfortable do you sense the intern is in relating to nursing and other staff members?

very uncomfortablevery comfortable

123456

Comments:

6)Please rate the intern's ability to function as a member of the health care team.

functions poorly as team memberexcellent team member

123456

Comments:

7)As a staff member, how comfortable would you be approaching this person for discussion or

consultation for a personal concern.

very uncomfortablevery comfortable

123456

Comments:

Please make any comments/observations that you feel would be important for the intern to be aware of.

Name (Optional) Date

Unit/Department Ext.

If you have any questions please call Jill Rasmussen-Baker, Clinical Pastoral Educator–6-4065 (546-4065).

Feedback form 01/2011

1

III-