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University of Manitoba

Department of Obstetrics & Gynecology

Clerkship Evaluation Mid-Rotation


Name of Clerk
Name of Evaluator
Evaluation Date

Criteria -

(For the following questions, any responses that are marked with an * must have a rationale for the rating.)

1* - Unsatisfactory -Does not meet the standard.
2 -   Satisfactory - Meets the standard.
3 -   Excellent - Exceeds the standard.

Interpersonal and Communication
1 = Unsatisfactory*2 = Satisfactory3 = Excellent
Works effectively with faculty, peers and health care team members.
Is sensitive to and communicates well with patients/families
Rationale for Rating - Interpersonal and Communication Skills: 
Patient Care
1- Unsatisfactory*2- Satisfactory3- Excellent
Gathers thorough and concise patient histories.
Interprets data, and uses medical knowledge to solve medical problems.
Notes are timely, accurate and thorough.
Seeks appropriate level of supervision.
Rationale for Rating - Patient Care:
Dependability / Responsibility
1 - Unsatisfactory*2 - Satisfactory3 - Excellent
Is dedicated and committed to fulfilling clerkship responsibilities.
Conscientious / punctual.
Seeks to contribute to patient care.
Makes efficient use of time.
Rationale for Rating - Dependability / Responsibility:
Are there any issues which may cause this student NOT to complete the rotation successfully?
If yes to question 11, have these issues been clearly discussed with the student?