Student Evaluation of the Clinical Placement and Instructor Clinical Facility: Internship: Dates: Area of Practice: Clinical Instructor: Clinical Instructor: CCCE: Student: The purpose of this form is: 1. To foster communication between the clinical instructor (CI) and student. 2. To provide constructive feedback to the clinical instructor. 3. To provide feedback to the facility/agency on the student s experience. 4. To provide feedback to the Director of Clinical Education (DCE) regarding the clinical experience. Instructions for use: Students are to complete this form at midterm and final evaluation. The form is to be discussed with the CI at mid-term and final points during the internship. Comments are extremely valuable and are strongly encouraged. Please append additional comments if required. Space for evaluation ratings are indicated at the end of each line. Please check the appropriate rating box according to the following scale: SA = A = N = D = SD = strongly agree agree neutral disagree strongly disagree This form is to be returned with your Clinical Performance Instrument (CPI) by your Site Coordinator to: Ann MacPhail, ACCE Attn: Bev Phillips School of Physical Therapy, Faculty of Health Sciences Elborn College, Room 1588, Western University 1201 Western Road London, ON, N6G 1H1 Student Evaluation of the Clinical Internship - 1 -
ORIENTATION SA A N D SD I was adequately oriented to the Site/Organization. I was adequately oriented to emergency and safety procedures. CASELOAD and PRACTICE The variety of conditions seen provided a useful learning experience. The caseload expectations were appropriate for my clinical level. There was adequate opportunity to practice taking a history. There was adequate opportunity to practice assessments and outcomes. There was adequate opportunity to practice problem identification. There was adequate opportunity to practice implementation of treatment plans. There was adequate opportunity to practice evaluation of treatment plan progression. There was adequate opportunity to practice recording patient care (documentation). There was adequate opportunity to practice discharge planning. There was adequate opportunity to practice communication with other members of the health care team. Student Evaluation of the Clinical Internship - 2 -
CLINICAL INSTRUCTOR and SUPERVISION (Students: please contact ACCE if you have significant concerns, at any time during the placement or afterwards) The general expectations, roles and responsibilities were discussed with the Clinical Instructor in the first week of the internship (ex. learning/teaching style, preferred methods of feedback). I was provided with timely and appropriate constructive feedback / suggestions for improvement. The CI allowed me appropriate progressive independence/responsibilities. The CI encouraged me to critically think through problems. The CI encouraged me to critically evaluate my own performance. The CI created an open environment and was receptive and responsive to my feedback. EVALUATION The CI s completed ACP accurately reflects the student s overall performance in the clinical setting. Student Evaluation of the Clinical Internship - 3 -
GENERAL The internship met my course objectives. Skills acquired in the classroom matched clinical practice expectations in the internship. Interaction with other health care professionals was available during the internship. Participation as part of the program/department/health care team was encouraged. Overall, the internship provided the learning experience required to develop basic competency in this area of practice, appropriate to my clinical level. 1. By the end of the placement, how would you rate this clinical placement experience? Excellent Very good Good Fair Poor 2. The most positive aspects of this internship were: Some suggestions for adding to the learning experience are: 3. Please note any significant discrepancies between method(s) used at site as opposed to method(s) taught in the school in the space below. Student Evaluation of the Clinical Internship - 4 -
Signatures National Association for Clinical Education in Physiotherapy Signatures Student Signature: CCCE Signature: Date: Student Signature: CCCE Signature: Date: Student Evaluation of the Clinical Internship - 5 -