Faculty evaluation – This form is anonymous. Do not put any identifying information on
this form.
NAME of PRECEPTOR: _________________________________
Number of clinics/on-call shifts worked with this preceptor:
3-5
6-9
10 or more
Medical expert
Application of knowledge 0
1
2
3
4
5
Procedural skills
0
1
2
3
4
5
Not applicable or not observed.
Seldom cites evidence to support clinical decisions.
Does not integrate basic science with clinical
knowledge. Unsure, hesitant.
Conveys an impression of gaps in knowledge.
Often fails to substantiate decisions with evidence.
Overall appropriate and adequate. Usually
substantiates decisions with evidence.
Focused and logical integration of basic scientific
principles and knowledge. Aware of methodological
issues. Substantiates decisions.
Displays mastery of subject matter. Always
substantiates decisions and integrates basic science
with evidence based clinical knowledge relevant to
solving clinical problems. Acknowledges
limitations of evidence.
Not applicable or not observed.
No guidance provided to learner.
Inconsistently assists learner in attaining proficiency of
procedural skill.
Adequate assistance provided and appropriate
method demonstrated.
Proficient. Assists and demonstrates how to perform task
optimally. Emphasizes how to minimize risk and
discomfort to patient.
Displays mastery in performing and teaching how to
perform task.
Communicator/collaborator
Level of responsibility
0
Not applicable or not observed.
1
2
3
4
5
Health care team
(nurses, others)
0
1
2
3
4
5
Makes learner feel redundant or insecure. Hard to get
hold of. Not available when needed.
Did not provide graded responsibility appropriate to
level of training or patient acuity.
Appropriate patient load and complexity for level of
training.
Learner felt responsible for patient care/treatment
planning while receiving adequate support and back
up.
Learner felt respected. Preceptor always ready to help
if needed.
Not applicable or not observed.
Unresponsive to questions/concerns of team members.
Inconsistent or less than optimal attention to team
members.
Responds appropriately to team members
questions/concerns.
Proactive approach. Responds quickly and effectively.
Facilitates involvement of team members.
Decisions made by team respected and supported by
preceptor.
Manager
Use of investigations
0
1
2
3
4
Not applicable or not observed.
No discussion of appropriateness of investigations.
Limited discussions.
Appropriate.
Discusses relevance and cost effectiveness of
investigations.
QA/QI
0
1
2
3
4
Not applicable or not observed.
Avoids participation in QA/QI
Silent participant in QA/QI
Appropriate involvement in QA/QI
Demonstrates mastery of QA/QI concepts and how to
apply them to improve patient outcomes.
Time management
0
1
2
Not applicable or not observed.
Frequently late for clinic. Disorganized.
Generally started and completed clinics within required
time frame.
3
Always organized, prepared. Never late.
0
1
2
Not applicable or observed.
Rarely identifies or reviews prevention strategies.
Recognizes opportunities when prevention counseling
could be offered.
Actively involves patient and family in prevention and
health promotion strategies.
Health advocacy
Health care promotion
3
Scholarly activity
Teaching skills
0
1
2
3
4
5
Feedback skills
0
1
2
3
4
5
Not applicable or not observed.
Rarely teaches. Unclear, limited or inappropriate
teaching to level of learner. Seldom observes trainee in
clinic or on ward.
Occasionally teaches. Borderline ability to teach to
level of trainee.
Teaches when requested. Teaching directed to
learner’s needs.
Motivates self directed learning. Observed trainee in
clinic or on ward. Scheduled regular teaching sessions.
Master teacher. Made teaching a priority.
Not applicable or not observed.
Hardly ever provided feedback. Almost always gave
negative feedback
Infrequent or non-specific feedback.
Regular feedback, both positive and negative.
Frequent, constructive feedback.
Immediate feedback with follow-up of deficiencies.
Professional
Patient care
0
1
2
3
Not applicable or not observed.
Lacks empathy. Makes disparaging remarks
of patient gender, race, disability, or socio-economic
status.
On occasion indifferent to patient needs.
Knows patients well. Demonstrates concern for patients’
well-being.
4
5
Relations with
colleagues and learners
0
2
3
4
5.
Excellent rapport with patient and families. Sensitive
and caring.
Provides exemplary patient centred care at all times.
Not applicable or not observed.
Fails to maintain appropriate boundaries in work and
learning situations. Makes disparaging remarks of coworker’s or learner’s gender, race, disability, or socioeconomic status.
Inconsistent behavior that detracts from learning
environment.
Appropriate professional interactions.
Develops positive relationships. Genuinely interested in
learner’s needs and/or difficulties.
Outstanding interpersonal skills. Superb teacher-learner
relationship.
Overall
0
1
2
3
Comments:
Do not wish to work with this preceptor again.
Some hesitation to work with this preceptor again.
Fine to work with this preceptor again.
One of the best preceptors I’ve worked with.