Clinical Simulation Feedback Log Form
Please complete the Clinical Simulation Feedback Log Form after your simulation session. Your feedback helps us improve the learning experience.
Participant Name
*
First Name
Last Name
Role or Position
*
Simulation Scenario/Topic
*
Simulation Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Facilitator or Observer Name
*
Overall Effectiveness Rating
*
Not effective
1
2
3
4
Highly effective
5
1 is Not effective, 5 is Highly effective
Communication/Teamwork Rating
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Clinical Skills Performance Rating
*
Needs improvement
1
2
3
4
Outstanding
5
1 is Needs improvement, 5 is Outstanding
Strengths Observed
Improvement Areas or Comments
Submit Feedback
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