Surgical Performance Evaluation Survey
Please complete this survey to assess surgical performance across key competency areas.
Evaluator's Full Name
*
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Surgeon's Full Name
*
First Name
Last Name
Surgical Procedure
*
Level of Training
*
Please Select
Resident
Fellow
Attending Surgeon
Other
Evaluate the following aspects of the surgical performance:
*
Rows
Poor
Fair
Good
Very Good
Excellent
Technical Skill
1
2
3
4
5
Aseptic Technique
6
7
8
9
10
Communication with Team
11
12
13
14
15
Decision Making
16
17
18
19
20
Adherence to Protocol
21
22
23
24
25
Time Management
26
27
28
29
30
Overall Surgical Performance
*
1
2
3
4
5
Was there any intraoperative complication?
*
No
Yes
Strengths Observed
Areas for Improvement
Additional Comments
Submit Evaluation
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