CLINICAL SUPERVISOR ASSESSMENT AND FEEDBACK FORM ORTHOPTICS CLINICAL PLACEMENTS PP1 of number of days attending clinic. To be completed at the conclusion of each student’s placement. Please use only ONE form per student irrespective ________________________________________________________________________________ Student’s Name: Dates placement attended: ______________________________________________________________________________ Clinical Supervisor: ____________________________ Placement Site: __________________________________ YES NO OVERALL RATING AND COMMENTS EFFECTIVE PROFESSIONAL & COMMUNICATION BEHAVIOUR – Please Please Please circle one Written and Verbal circle circle Still to achieve / achieving / highly achieving Develops rapport and is able to interact with patients and Yes No Comments: staff Demonstrates professional, respectful and courteous Yes No behaviour with patients and staff Is punctual and Presentation is neat and tidy Yes No Student demonstrates initiative in seeking experience and offering assistance Yes No Student freely presents learning goals and asks respectfully for help to achieve them Yes No Students demonstrates active learning within an observational environment (asks relevant questions about Yes No assessment technique, results or patient management) Yes No Student is respectful of patient confidentiality If given the opportunity - Demonstrates the ability to adapt Yes No communication skills toward patients if required including the tone and language used toward the patients
CLINICAL SUPERVISOR ASSESSMENT AND FEEDBACK FORM ORTHOPTICS CLINICAL PLACEMENTS PP1 To be completed at the conclusion of each student’s placement. Please use only ONE form per student irrespective of number of days attending clinic. Student’s Name: ________________________________________________________________________________ Dates placement attended: ______________________________________________________________________________ Clinical Supervisor: ____________________________ Placement Site: __________________________________ EFFECTIVE PROFESSIONAL & COMMUNICATION BEHAVIOUR – Written and Verbal YES Please circle NO Please circle OVERALL RATING AND COMMENTS Please circle one Develops rapport and is able to interact with patients and staff Demonstrates professional, respectful and courteous behaviour with patients and staff Is punctual and Presentation is neat and tidy Student demonstrates initiative in seeking experience and offering assistance Student freely presents learning goals and asks respectfully for help to achieve them Students demonstrates active learning within an observational environment (asks relevant questions about assessment technique, results or patient management) Student is respectful of patient confidentiality If given the opportunity - Demonstrates the ability to adapt communication skills toward patients if required including the tone and language used toward the patients Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No Still to achieve / achieving / highly achieving Comments:
PP1_Supervisor%20Assessments_UTS_GSHOrthoptics.docx