Emergency Medicine Residency Evaluation Form
Candidate Name
First Name
Last Name
Faculty Interviewer
Please Select
Jamal Hussain,MD
Kyle Wasserman, MD
Greg Corcoran, MD
Chhaya Patel, DO
Lara Samson, MD
Anuja Trivedi, DO
Interview Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
List three concerns of the Candidate's ability to function within the interview process
List three positives
What is your OVERALL evaluation of the candidate
UNACCEPTABLE
ACCEPTABLE, but I have MAJOR RESERVATIONS about this candidate.
ACCEPTABLE, but I have MINOR CONCERNS about the candidate.
GOOD SOLID CANDATE, I predict he/she will do well in the program.
HIGHLY DESIRABLE, I predict he/she will be an above average resident.
SUPERSTAR, I predict he/she will be one of the best residents we ever had.
Commitment to Emergency Medicine
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Recommendations
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Personal Statement
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
InterviewÂ
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Comments:
Submit
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