Fellow Peer-to-Peer Evaluation
Fellow:
Evaluation Period:
Evaluation of Fellow
Evaluator:
Rotation Name:
[First Name] [Last Name]
[99/99/9999] to [99/99/9999]
[First Name] [Last Name]
[Rotation Name]
Interpersonal and Communication Skills
Does not establish even minimally effective therapeutic
relationships with patients and families; does not
demonstrate ability to build relationships through
listening, narrative or nonverbal skills; does not provide
education or counseling to patients, families, or
colleagues.
Establishes a highly effective therapeutic relationship
with patients and families; demonstrates excellent
relationship building through listening, narrative and
nonverbal skills; excellent education and counseling of
patients, families, and colleagues; always
"interpersonally" engaged.
Strongly Disagree
Disagree
Neither Disagree nor
Agree
Agree
Strongly Agree
1
2
3
4
5
Not Applicable
,7560743_1
Medical Knowledge
Limited knowledge of basic and clinical sciences;
minimal interest in learning; does not understand
complex relations, mechanisms of disease.
Exceptional knowledge of basic and clinical sciences;
highly resourceful development of knowledge;
comprehensive understanding of complex relationships,
mechanisms of disease.
Strongly Disagree
Disagree
Neither Disagree nor
Agree
Agree
Strongly Agree
1
2
3
4
5
Not Applicable
,7560744_1
Patient Care and Procedural Skills
Inept, careless, disregards risk and discomfort to patient
Proficient, minimizes patient's discomfort.
Displays caring/respectful behavior; Performs accurate,
comprehensive interviews; Capable of formulating diagnosis and
making informed decisions; Counsels and educates patients and
families. Performs well within a team.
Strongly Disagree
Disagree
Neither Disagree nor
Agree
Agree
Strongly Agree
1
2
3
4
5
Not Applicable
,7560745_1,7560
Practice-Based Learning and Improvement
Fails to perform self-evaluation; lacks insight, initiative;
resists or ignores feedback; fails to use information
technology to enhance patient care or pursue selfimprovement.
Constantly evaluates own performance, incorporates
feedback into improvement activities; effectively uses
technology to manage information for patient care and
self-improvement.
Strongly Disagree
Disagree
Neither Disagree nor
Agree
Agree
Strongly Agree
1
2
3
4
5
Not Applicable
,7560748_1
Professionalism
Frequently irresponsible, unreliable, and uncommitted.
Ineffective communicator. Disruptive and disrespectful
to other health care professionals. Shows disdain for
professional colleagues. Records frequently tardy and
illegible, even though complete and accurate.
Enthusiastic. Responsive, reliable, committed,
cooperative, and respectful. Provides effective
communication. Shows regard for opinions and skills of
professional colleagues. Displays initiative and provides
leadership.
Strongly Disagree
Disagree
Neither Disagree nor
Agree
Agree
Strongly Agree
1
2
3
4
5
Not Applicable
,7560749_1
System-Based Practices
Unable to access/mobilize outside resources; actively
resists efforts to improve systems of care; does not use
systematic approaches to reduce error and improve
patient care.
Effectively accesses/utilizes outside resources;
effectively uses systematic approaches to reduce errors
and improve patient care; enthusiastically assists in
developing systems' improvement.
Strongly Disagree
Disagree
Neither Disagree nor
Agree
Agree
Strongly Agree
1
2
3
4
5
Not Applicable
,7560611_1
Miscellaneous Questions
What obstacles, if any, are you experiencing that impede (your or your peer) professional growth?
,7560750_1
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Comments (Please write about Strengths, Weaknesses and Areas for Improvement)
Optional Comments Section:
* * Confidential Comments (The following comments will only be seen by the Program Director) * *