Clinical Experience Assessment Form
Please complete this form to provide feedback on your recent clinical experience. Your input will help us improve future training and placements.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Clinical Site/Facility Name
*
Supervisor/Preceptor Name
*
Dates of Clinical Experience
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please indicate your role during this clinical experience.
*
Please Select
Student
Intern
Resident
Nurse
Physician
Other
Please rate the following aspects of your clinical experience:
*
Rows
Excellent
Good
Fair
Poor
Orientation to the clinical site
1
2
3
4
Support from supervisor/preceptor
5
6
7
8
Opportunities for hands-on learning
9
10
11
12
Quality of patient care environment
13
14
15
16
Availability of learning resources
17
18
19
20
How would you rate your overall clinical experience?
*
1
2
3
4
5
Which clinical skills did you practice or develop during this experience? (Select all that apply)
*
Patient assessment
History taking
Physical examination
Procedural skills
Communication with patients
Teamwork/interprofessional collaboration
Documentation/charting
Other
What were the strengths of your clinical experience?
What challenges or areas for improvement did you encounter?
Additional comments or suggestions for future clinical experiences:
Submit Assessment
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