Institutional Professionalism Evaluation Form _________________________________ Student Name _ _ Administrator Date of incident(s) & location Administrator’s Signature Date Date this form was discussed with the student __________________ Other staff present _______ A student with a pattern of the following behavior has not sufficiently demonstrated professional and personal attributes for meeting the standards of professionalism inherent in being a physician and a student at NJMS: Circle the appropriate category(ies). Comments are required. Unmet professional responsibility: The student needs continual reminders in the fulfillment of administrative responsibilities, such as: immunization requirements, billing or financial aid deadlines, USMLE deadlines, registration tasks, FIT testing, annual corporate training and compliance duties, etc. The student cannot be relied upon to complete assigned tasks by the given deadline. The student communicates in a manner that is arrogant, abusive, or otherwise unprofessional. The student has demonstrated a pattern of tardiness for an appointment or event without advance notification. The student does not work cooperatively with administrative staff. The student is disruptive in various settings.
Institutional Professionalism Evaluation Form _________________________________ Student Name _ _ Administrator Date of incident(s) & location Administrator’s Signature Date Date this form was discussed with the student __________________ Other staff present _______ A student with a pattern of the following behavior has not sufficiently demonstrated professional and personal attributes for meeting the standards of professionalism inherent in being a physician and a student at NJMS: Circle the appropriate category(ies). Comments are required. Unmet professional responsibility: The student needs continual reminders in the fulfillment of administrative responsibilities, such as: immunization requirements, billing or financial aid deadlines, USMLE deadlines, registration tasks, FIT testing, annual corporate training and compliance duties, etc. The student cannot be relied upon to complete assigned tasks by the given deadline. The student communicates in a manner that is arrogant, abusive, or otherwise unprofessional. The student has demonstrated a pattern of tardiness for an appointment or event without advance notification. The student does not work cooperatively with administrative staff. The student is disruptive in various settings.
NJMSStandardsofProfessionalismforweb62014.docx