Clinical Experience Site Evaluation Form - School of Nursing ...
Clinical Experience Site Evaluation Form - School of Nursing ...
Clinical Experience Site Evaluation Form - School of Nursing ...
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<strong>Form</strong> #9<br />
University <strong>of</strong> Minnesota<br />
<strong>School</strong> <strong>of</strong> <strong>Nursing</strong><br />
Nurse-Midwifery and Women’s Health Nurse Practitioner Program<br />
<strong>Clinical</strong> <strong>Experience</strong> <strong>Site</strong> <strong>Evaluation</strong> <strong>Form</strong><br />
<strong>Site</strong>:<br />
Semester(s): _____________________________<br />
Course: __________________________ Person evaluating: Student Faculty<br />
Please rate and comment on the following areas. Please <strong>of</strong>fer any suggestions for change as well as comments<br />
about what was helpful. Please be as specific as you can. Thank you.<br />
Inadequate<br />
Fairly<br />
Adequate<br />
Adequate<br />
More than<br />
Adequate<br />
1. Physical layout:<br />
A. Adequate space .................................................................<br />
B. Availability and condition <strong>of</strong> equipment ..........................<br />
1<br />
1<br />
2<br />
2<br />
3<br />
3<br />
4<br />
4<br />
2. Orientation to facility:<br />
A. Staff supportive <strong>of</strong> student role.........................................<br />
B. Protocols / practice guidelines available...........................<br />
C. Student=s function and responsibility clear......................<br />
D. Consultation mechanisms available..................................<br />
E. Adequacy <strong>of</strong> time allowed to see clients...........................<br />
1<br />
1<br />
1<br />
1<br />
1<br />
2<br />
2<br />
2<br />
2<br />
2<br />
3<br />
3<br />
3<br />
3<br />
3<br />
4<br />
4<br />
4<br />
4<br />
5<br />
3. <strong>Clinical</strong> preceptor/faculty and student communication:<br />
A. Availability to student ......................................................<br />
B. Adequate supervision/communication..............................<br />
C. Provision <strong>of</strong> timely evaluation and feedback....................<br />
D. Students allowed to select clients according to needs ......<br />
1<br />
1<br />
1<br />
1<br />
2<br />
2<br />
2<br />
2<br />
3<br />
3<br />
3<br />
3<br />
4<br />
4<br />
4<br />
4<br />
4. <strong>Clinical</strong> experience:<br />
A. Availability <strong>of</strong> numbers <strong>of</strong> clients ....................................<br />
B. Diversity <strong>of</strong> types <strong>of</strong> clients ..............................................<br />
C. Continuity <strong>of</strong> care / able to follow-up clients, lab work ...<br />
D. Opportunities to refer to / interact with other agencies /<br />
resources ...........................................................................<br />
E. Instructional materials available to clients ........................<br />
1<br />
1<br />
1<br />
1<br />
1<br />
2<br />
2<br />
2<br />
2<br />
2<br />
3<br />
3<br />
3<br />
3<br />
3<br />
4<br />
4<br />
4<br />
4<br />
4<br />
5. Would you recommend this site to another student? Yes _____ No _____<br />
Comments:
Place a name <strong>of</strong> a preceptor (up to four) that you worked with the most during the semester in the top boxes in this<br />
chart. In each box under the preceptor’s name, please rate the individual for each statement using the following<br />
scale: 5=strongly agree; 4=agree; 3= neutral; 2=disagree and 1=strongly disagree<br />
Preceptor Name →<br />
• Provided timely and<br />
helpful feedback<br />
• Modeled pr<strong>of</strong>essional<br />
behavior<br />
• Treated me with respect<br />
and without discrimination<br />
• Demonstrated competent<br />
clinical care<br />
• Provides clear information<br />
and feedback about ongoing<br />
clinical progress<br />
Please add any additional comments:<br />
Rev. 6-19-01<br />
F/site.eval.doc
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