Critical Concepts Professionalism Evaluation Form
After completion, return card to Jennifer Jeansonne, UME Coordinator, Learning Center Room 615
Student Name: __________________________ _________
Date of Rotation: _____________________________________
Please place an “X” in the appropriate box for each of the following evaluation areas:
Did the student
participate actively in
patient care?
YES
NO
PROFESSIONAL CHARACTERISTICS – ER Shifts
Did the student show
Did the student show
Evaluator’s Signature (Faculty or Sr. Resident)
respect for colleagues,
interest in learning and
patients, and staff?
self-improvement?
YES
NO
YES
NO
ER Shift 1
ER Shift 2
ER Shift 3
ER Shift 4
ER Shift 5
ER Shift 6
For every NO checked above, please provide a comment:
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Does this student’s performance on this rotation warrant attention?
YES
NO
PROFESSIONAL CHARACTERISTICS – ICU Week
Did the
student
participate
actively in
patient care?
YES
NO
Did the
student show
respect for
colleagues,
patients, and
staff?
YES
NO
Was the student
punctual and
reliable?
YES
Did the student
show interest in
learning and selfimprovement?
NO
YES
NO
Did the student
show personal
integrity and
honesty?
YES
Faculty Evaluator’s Signature
NO
ICU Week
For every NO checked above, please provide a comment:
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Does this student’s performance on this rotation warrant attention?
YES
NO
DIDACTIC WEEK ATTENDANCE AND PARTICIPATION RECORD
Introduction to EM
General Surgery
Anesthesia
Urology
Orthopedics
Faculty Signature
PICU/NICU
Faculty Signature
Psychiatry
Faculty Signature
Pulmonary/ICU
Faculty Signature
OB/GYN
Faculty Signature
Faculty Signature
Faculty Signature
Faculty Signature
Faculty Signature
OFF