Clinical Staff Relief Performance Evaluation Form printable pdf download

Concordia College Dietetic Internship

Clinical Staff Relief Performance Evaluation Form

Intern Name _____________________________________________________

Rotation Site _____________________________________________________

Rotation Dates __________________________ to _______________________

Preceptor ________________________________________________________

Date of evaluation _________________________________________________

Please check:

Mid-point Evaluation ____

Final Evaluation ____

Please check:

Preceptor-Evaluation ____

Intern-Evaluation ____

This form is divided into three sections based on the skills which the intern

develops to become an entry level dietitian. Please record the numeric value (1 - 6)

for each objective using the rating scale provided at the top of each page. Space is

provided after each objective for additional comments and explanation. If either

the intern or preceptor feels there was no opportunity to observe an objective, N/A

should be written in the space allotted for checking the rating scale.

The performance evaluation is used at both the middle and end of the clinical

experience.

The evaluation given at mid-point will include Section III where

appropriate.

This will encourage discussion about the intern’s increasing

responsibility towards assuming the staff relief role. The mid-point evaluation will

provide guidance for the intern and will not count toward the competency score

The final evaluation will be a major consideration for the score the intern receives

on the following competencies: CD 3.1, 3.1.a, 3.1.b, 3.1.c, 3.1.d, 3.5, and 4.11.

The intern should evaluate himself/herself before meeting with the

preceptor. The preceptor should also complete his/her evaluation of the intern

before the evaluation meeting. At the time of evaluation, discrepancies should be

discussed.

It should be expected that for the beginning intern, the level of achievement for most of the

objectives will not be above 3 or 4 on the rating scale at the mid-point evaluation.

Updated June 2014

Clinical Staff Relief Performance Evaluation Form