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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 Program) ____________________
Site ____________________
Rotation dates ____________________
Please assess the PA student in each of the categories listed below by rating the student’s performance:
4= Exceeds expectations
3= Meets expectations
2= Needs improvement
1= Does not meet expectations
N/A= Not observed or not applicable
Clinical Knowledge and Skills Interpersonal Skills and Professionalism 
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 to 843-792-9172, or email to or Postal Service mail to:
PA Studies, Clinical Coordinator, 151 B Rutledge Ave., (MSC 962) Suite B 102, Charleston, SC 29425

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