Final Evaluation Form: CFPC-EM Program

October 30, 2000

Name

Year

Director

Anesthesia

Inadequate (1-2) well-balanced(3) excessive(4-5)

12345N/A

Workload during shifts

Schedule

Clinical teaching

Procedures

Time for self-learning

Degree of Supervision

Degree of Autonomy

Accolades to:

Comments:

St. Boniface Emergency

Inadequate (1-2) well-balanced(3) excessive(4-5)

12345N/A

Workload during shifts

Schedule

Clinical teaching

Procedures

Time for self-learning

Degree of Supervision

Degree of Autonomy

Accolades to:

Comments:

Pediatric Emergency

Inadequate (1-2) well-balanced(3) excessive(4-5)

12345N/A

Workload during shifts

Schedule

Clinical teaching

Procedures

Time for self-learning

Degree of Supervision

Degree of Autonomy

Accolades to:

Comments:

HSC Emergency

Inadequate (1-2) well-balanced(3) excessive(4-5)

12345N/A

Workload during shifts

Schedule

Clinical teaching

Procedures

Time for self-learning

Degree of Supervision

Degree of Autonomy

Accolades to:

Comments:

Trauma Surgery

Inadequate (1-2) well-balanced(3) excessive(4-5)

12345N/A

Workload during shifts

Schedule

Clinical teaching

Procedures

Time for self-learning

Degree of Supervision

Degree of Autonomy

Accolades to:

Comments:

MICU

Inadequate (1-2) well-balanced(3) excessive(4-5)

12345N/A

Workload during shifts

Schedule

Clinical teaching

Procedures

Time for self-learning

Degree of Supervision

Degree of Autonomy

Accolades to:

Comments:

SICU

Inadequate (1-2) well-balanced(3) excessive(4-5)

12345N/A

Workload during shifts

Schedule

Clinical teaching

Procedures

Time for self-learning

Degree of Supervision

Degree of Autonomy

Accolades to:

Comments:

Selective (specify______)

Inadequate (1-2) well-balanced(3) excessive(4-5)

12345N/A

Workload during shifts

Schedule

Clinical teaching

Procedures

Time for self-learning

Degree of Supervision

Degree of Autonomy

Accolades to:

Comments:

Selective (specify______)

Inadequate (1-2) well-balanced(3) excessive(4-5)

12345N/A

Workload during shifts

Schedule

Clinical teaching

Procedures

Time for self-learning

Degree of Supervision

Degree of Autonomy

Accolades to:

Comments:

Research Project

Inadequate (1-2) well-balanced(3) excessive(4-5)

12345N/A

Workload

Preparation time

Access to Resources

Degree of Supervision

Feedback after Presentation

Disagree(1-2) Neutral(3) Agree(4-5)

12345N/A

Was useful

Taught Critical Appraisal skills

Encouraged further research

Accolades to:

Comments:

Academic Halfday

Inadequate (1-2) well-balanced(3) excessive(4-5)

12345N/A

Workload

Preparation time

Access to Resources

Degree of Supervision

Organization

Accolades to:

Comments:

Other:

Please comment on the strengths and/or weaknesses of the following:

Director-Resident meetings:

Lifeflight:

Sexual Assault Protocol Experience:

Elective:

(How did you use your elective time?)

Please submit this final evaluation form to the Emergency Medicine Office at A1119, SBGH, 409 Tache Avenue, Winnipeg, MB, R2H 2A6, Attention: Administrative Assistant.

Revised June 2007