PACIFIC UNIVERSITY
ATHLETIC TRAINING
EVALUATION OF CLINICAL INTERNSHIP IV
Student Name:_______________________________________________________________
Preceptor:___________________________________________________________________
Clinical Site:__________________________________________________________________
Evaluation Type:
Midterm
Final
Directions: Please evaluate the athletic training student using the following criteria.
3=Entry Level
2=Developing Skills
1=Needs Improvement
NA=Not Observed or Not Applicable for this rotation
Professionalism:
1. Is punctual and reliable
3
2
1
NA
2. Appropriate dress and behavior
3
2
1
NA
3. Demonstrates a positive attitude
3
2
1
NA
4. Demonstrates initiative to learn
3
2
1
NA
5. Completes assigned tasks in a timely manner
3
2
1
NA
6. Follows policies and procedures
3
2
1
NA
7. Complies with OSHA and HIPAA standards
3
2
1
NA
8. Communicates effectively
3
2
1
NA
9. Uses appropriate medical terminology
3
2
1
NA
Clinical Skills and Proficiencies:
1.
Injury Evaluation:
Upper extremity
Lower extremity
Head
Neck
Thorax
Spine
3
3
3
3
3
3
2
2
2
2
2
2
1
1
1
1
1
1
NA
NA
NA
NA
NA
NA
2.
Documentation
3
2
1
NA
3.
Acute care and treatment
3
2
1
NA
4.
Establishment of treatment goals
3
2
1
NA
5.
Appropriate use of therapeutic
interventions
3
2
1
NA
6.
Rehabilitation:
3
3
3
3
3
2
2
2
2
2
1
1
1
1
1
NA
NA
NA
NA
NA
Return-to-play decisions
3
2
1
NA
8. Identifying activity restrictions
3
2
1
NA
9. Patient referral
3
2
1
NA
10. Examination of patient who is ill
3
2
1
NA
11. Appropriate emergency care:
3
2
1
NA
Vital signs
Activation of EAP
On-field management
Primary survey
Secondary survey
Diagnosis
Follow-up
3
3
3
3
3
3
3
2
2
2
2
2
2
2
1
1
1
1
1
1
1
NA
NA
NA
NA
NA
NA
NA
Program design
Patient Instruction
Patient supervision
Implementation
Progression & modification
7.
12. Knowledge and use of patient-file management system:
Documentation
Risk management
Outcomes
Billing
3
3
3
3
2
2
2
2
1
1
1
1
NA
NA
NA
NA
Please identify the student’s strengths.
Please identify the student’s areas for improvement.
Has the student met expectations for this clinical? If not, why?
If you were to assign an overall letter grade to the student for this clinical experience, what grade would
you assign?
______________________________________
Preceptor
Date
______________________________________
Clinical Education Coordinator
Date
_______________________________________
Student
Date