Pre-clerkship and Clinical _ Student Name Course/Clerkship Title _ _ Course Director/Clerkship Director/Faculty Date of incident(s) & location Course Dir./Clerkship Dir./Faculty 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: Circle the appropriate category(ies). Comments are required. Unmet professional responsibility: The student cannot be relied upon to complete assigned tasks. The student needs continual reminders in the fulfillment of responsibilities to patients or to other health care professionals. The student has unexcused absences from course/clerkship requirements. The student is frequently tardy for course/clerkship requirements. The student does not work cooperatively with his/her peers. The student is disruptive in the learning environment. The student did not report a violation of the NJMS Code of Professional Conduct. 2. Lack of effort toward self-improvement and adaptability: a. The student is resistant or defensive in accepting criticism. The student remains unaware of his/her own inadequacies, and makes no effort to understand them.
Pre-clerkship and Clinical _ Student Name Course/Clerkship Title _ _ Course Director/Clerkship Director/Faculty Date of incident(s) & location Course Dir./Clerkship Dir./Faculty 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: Circle the appropriate category(ies). Comments are required. Unmet professional responsibility: The student cannot be relied upon to complete assigned tasks. The student needs continual reminders in the fulfillment of responsibilities to patients or to other health care professionals. The student has unexcused absences from course/clerkship requirements. The student is frequently tardy for course/clerkship requirements. The student does not work cooperatively with his/her peers. The student is disruptive in the learning environment. The student did not report a violation of the NJMS Code of Professional Conduct. 2. Lack of effort toward self-improvement and adaptability: a. The student is resistant or defensive in accepting criticism. The student remains unaware of his/her own inadequacies, and makes no effort to understand them.
NJMSStandardsofProfessionalismforweb72013.docx