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UIC Family Medicine Clerkship Evaluation Form

1. STUDENT/SITE INFORMATION

Fill in all blanks with asterisk*

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* 1. Student Name:

First Name:

Last Name:

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* 2. Preceptor:

First Name:

Last Name:

Degree(s):

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* 3. Clerkship Site:

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* 4. Position:

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* 5. Block (Timeframe precepted):

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* 6. Instructional Setting:

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* 7. Total Number of Half-Days Precepted:

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* 8. Total Number of Patient Encounters DIRECTLY Observed: