M4 Student Performance Evaluation Preceptor InformationDate MM slash DD slash YYYY Evaluator Name First Last Practice NameDo you have any conflict of interest in evaluating this student, such as having previously treated the student as a patient or having a family or financial relationship with the student? Yes No History and Physical Exam SkillsHistory Taking Skills(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation Physical Exam Skills(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation Problem Solving Skills(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation Ability to Apply Knowledge(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation Behavior as a StudentIn relation to patients(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation In relation to support personnel(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation In relation to faculty(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation Appearance(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation Attendance, participation(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation Initiative(Required) Outstanding Above Average Average Below Average Unsatisfactory Insufficient Observation What are this student's greatest strengths?What are areas for improvement?Enter any additional comments.
