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National Midwifery Institute, Inc.
Preceptor Evaluation of Student
Student__________________________ Preceptor___________________________
Date______________________
___3 Month ___6 Month ___9 Month
Note: If student apprentice is providing supervised primary care, use the Midwifery Skills Evaluation form instead of
this one. That form is found in the Supervised Primary Care section of forms.
Instructions:
Preceptors use this form to evaluate the student; students use an identical form for self-assessment.
Please rate the following aspects of the apprenticeship on a scale of 1-10, 10 being the highest score. There is space after
each question to make written comments; use extra paper if necessary. Your honest feedback serves to uphold our
program’s commitment to provide the best possible educational experience for all of our students.
1) Student’s communication skills:
____ a) with clients;
SAMPLE
____ b) with precepting midwife;
____ c) with other practitioners;
____ d) with other faculty members.
2) Student takes the opportunity to:
____ a) be included as part of the care giving team;
____ b) express concerns regarding clients’ physical or emotional well-being;
____ c) understand decisions made by preceptor;
____ d) discuss birth experiences critically and constructively;
____e ) practice developing skills and accept guidance;