Surgery Student Evaluation Form
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1SURGERY STUDENT EVALUATION FORM
Date: __/__-__/__/09
Evaluation for: ___________
Freshman
Sophomore
______
____________
Junior
______
Senior
__X__
Uses of this evaluation:
When reported from your department, this evaluation becomes a part of this student’s
permanent record in the Dean’s Office. It will be used (1) by the Student Affairs Committee and by the Medical School
Administration whenever it bears on problems or awards concerning this student, and (2) as a significant part of any
letter of recommendation (for externship, internship, residency, etc. for this student coming from the Dean’s Office.)
FACULTY COMMENTS:
(Please summarize this student’s chief characteristics)
numerical grade
90-100
honors
80-89
high pass
70-79
pass
below 70 fail
Dr. ______________________________________________________________________________________
Printed/Typed Evaluator’s Name
Signature of Evaluator
Inadequate
Superior
Above Average
Average
Below Average
Unsatisfactory
Basis for
Judging
Basis & Technical Skills
(laboratory, bedside, etc.)
Reasoning, ability, application
of knowledge
Expression: oral & written
Relationship with others
(faculty, students, patients)
General appearance, poise &
manners
Maturity (emotional stability,
adaptability, self-confidence)
Reliability, responsibility
Interest, enthusiasm &
intellectual curiosity
GENERAL
RECOMMENDATION
FOR THE PROFESSION
Please fax to Patricia Kirsch at 504-988-1882 (# 504-988-3909)
Z:\Users\pkirsch\Seniors\evalfrm
May 13, 2008
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