Teach-Back Evaluation Form
Use this Teach-Back Evaluation Form to document understanding, identify gaps, and plan appropriate follow-up.
Evaluator name
*
Evaluation date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Topic or instructions reviewed
*
Participant’s explanation in their own words
*
Understanding criteria
*
Rows
Needs clarification
Partially demonstrated
Clearly demonstrated
Explains the main idea or purpose
1
2
3
Describes the key steps or instructions
4
5
6
Identifies when or how to apply the information
7
8
9
Uses their own words rather than repeating phrases
10
11
12
Overall understanding
*
1
2
3
4
5
Participant-reported confidence
*
1
2
3
4
5
Misunderstandings or gaps identified
Follow-up needed
*
No follow-up needed
Clarify specific points
Repeat the explanation and teach-back
Follow-up notes or next steps
Submit evaluation
Should be Empty: