Externship Site Evaluation Form

2008-2009
Evaluation Form(SQL version 7.5 with required comments & outcomes)

Fields marked with an asterisk * are required.

Name of Site*
Attending Doctor*
Extern*
Graduation Year
Extern email address*
Term*

Evaluation of Attending Doctor

Please select 1 for the lowest and 5 for the highest.

Basic attributes:
1. Is skilled in clinical techniques.
2. Is knowledgeable about alternative procedures and techniques.
3. Discusses recent developments in optometry when appropriate.
Rapport with students:
4. Presents facts and concepts about patient care decisions.
5. Emphasizes conceptual understanding.
6. Is friendly toward students.
7. Relates to students as individuals.
8. Approaches teaching and the externship program with enthusiasm.
9. Has an interest in student development as clinicians.
10. Invites students to share their knowledge and experiences.
11. Encourages student questions and discussion.
12. Helps students organize their thinking for problem solving.
13. Corrects student mistakes constructively.
14. Suggests specific ways a student can improve.
15. Tells students when they have done a particularly good job.
16. Consistently assesses student progress.
Rapport with patients:
17. Demonstrates sensitivity to the particular needs of patients.
18. Considers the social and psychological aspects of patient care.
19. Performs tests and procedures on patients when indicated.
20. Speaks directly to the patient about the assessment and management plan.
21. Maintains rapport with patients.

Evaluation of site

22. This externship has met your externship rotation expectations.

23. The facilities were adequate for performing necessary tests and evaluations.

24. How would you rate this site for continued externship utilization?

A short comment is required on Question # 24. (Max. 800) *

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25. What new optometric skills have you acquired? How have your optometric skills been enhanced at this rotation?(Max 999 characters) *

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Questions? e-mail Dr. Alex Harris, Coordinator of Externship Programs (314-516-5603) Questions? e-mail Yolanda Flanigan, Support Staff for Externship Programs

Remember to submit your case reports electronically here

Webmaster: Dr. Ralph Garzia & Sharon Rose J
Last Updated: August - 14 - 2007