OB/GYN CLERKSHIP CONTINUOUS FEEDBACK FORM

STUDENTS NAME: _________________________________ SITE (Circle): UH TCH St. E B-North GSH Clerkship Dates: Sept. 9 Oct. 18, 2013

Each week, pick at TWO goals between the student and the resident/faculty preceptor. The purpose of this is for the student to individualize their learning experience. Goals may include history-taking skills, exam skills, diagnostic skills, technical skills, or patient management skills. As the student is observed doing histories, exams, & patient presentations each week, ideas for individual goals will surface. Individual progress with these important skills can be measured and feedback given.

1st week Goals: OB Days-- OB NightsMFMGYN--GYN Onc--Outpt. 1.

COMMENTS:

2.

Resident/Faculty Preceptor:

2nd week Goals: OB Days-- OB NightsMFMGYN--GYN Onc--Outpt. 1.

COMMENTS:

2.

Resident/Faculty Preceptor:

3rd week Goals: OB Days-- OB NightsMFMGYN--GYN Onc--Outpt. 1.

COMMENTS:

2.

Resident/Faculty Preceptor:

STUDENTS NAME: _________________________________ Clerkship Dates: Sept. 9 Oct. 18, 2013 SITE (Circle): UH TCH St. E B-North GSH
4th week Goals: OB Days-- OB NightsMFMGYN--GYN Onc--Outpt. 1. COMMENTS:

2.

Resident/Faculty Preceptor:

5th week Goals: OB Days-- OB NightsMFMGYN--GYN Onc--Outpt. 1.

COMMENTS:

2.

Resident/Faculty Preceptor:

6th week Goals: OB Days-- OB NightsMFMGYN--GYN Onc--Outpt. 1.

COMMENTS:

2.

Resident/Faculty Preceptor:

(Choose either 2 x 12-hr. shifts or 1 x 24 hr. shift) Call Dates Hours Physician Signoff ______________ ______________
Revised 6/17/2013

Observed Speculum & Bimanual Exam: Date: ___________________ Supervising Provider Signature: _______________________________________

__________ __________

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