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Preceptor Evaluation of PA Student

Student ____________________
Rotation No. (1-9) ____________________
Preceptor’s Name and Title ____________________
Medical Discipline Completed ____________________
Supervising Physician (as identified by PA Studies Program) ____________________
Site ____________________
Date of Rotation ____________________

Please assess the PA student in each of the categories listed below by rating the student’s performance:
4= Exceeds expectations 3= Meets expectations 1= Does not meet expectations N/A= Not observed or not applicable

A. Medical interviewA.          1. Relating to Colleagues1.              
B. Physical examinationB.          2. Relating to Patients2.              
C. Oral case presentationC.          3. Understanding of PA role and recognition of limitations3.              
D. Written patient recordD.          4. Self-confidence4.              
E. Appropriate laboratory tests knowledge & utilizationE.          5. Reliability, Dependability & attendance5.              
F. Clinical proceduresF.           6. Professionalism6.              
G. Clinical reasoning and problem

7. Attitude7.              
H. Factual knowledge & conceptsH.          8. Appearance8.              
I. Assessment and differential
J. Ability to form and implement a
management plan
J.          Number of Absences __           

Do you have any reservations about the clinical competency of this student?

Yes     No

Do you have reservations about the professional behavior of this student?

Yes     No

Do you desire a phone call from a clinical coordinator regarding this student?

Yes     No





Preceptor’s signature                                                                                    Date                                 

Student’s signature after review                    ­­________                        _    Date ___                          

FAX:   843-792-9172 or 792-0506  E-mail:  Phone: 843-792-1913
Mail:  PA Division (B-103), 151-B Rutledge Ave. (MSC 962), Charleston, SC, 29425.

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