Student Performance Evaluation Form Utmb School Of Medicine Ambulatory Community Selective Page 2

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7. Written Assignment – If applicable, did the student complete the written assignment and turn it in for your evaluation?
Comment required to justify any rating above or below expected level of performance:
Completed
_____________________________________________________________
Not completed
_____________________________________________________________
Please comment on the student’s depth of thought on this written assignment:
Comment required to justify any rating above or below expected level of performance:
Exceeds expected level of performance
_____________________________________________________________
At expected level of performance
_____________________________________________________________
Below expected level of performance
_____________________________________________________________
Cannot evaluate this item
_____________________________________________________________
8. Comments regarding summary of student performance / goals for future development:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Number of student absences during 4-week period: _____________
Your signature confirms that this student spent at least 50% of their time in the clinical setting.
Instructor Signature: ______________________________
Date: ___________________________
Campus Faculty Only:
Written Assignment – If applicable, did the student complete the written assignment and turn it in for your evaluation?
Comment required to justify any rating above or below expected level of performance:
Completed
__________________________________________________________
Not completed
__________________________________________________________
Please comment on the student’s depth of thought on this written assignment:
Comment required to justify any rating above or below expected level of performance:
Exceeds expected level of performance
__________________________________________________________
At expected level of performance
__________________________________________________________
Below expected level of performance
__________________________________________________________
Cannot evaluate this item
__________________________________________________________
Additional Comments:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
FINAL GRADE
__________ Satisfactory
__________ Fail
(Check one)
Course Director Signature: _________________________
Date: ___________________________

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