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Summative-in-Training Assessment (SITA) Form

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* Date SITA form completed

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* Trainee Name

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* Supervisor of Training

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* Clinical Supervisor

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* Report Period

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* Full-time or Part-time training

Full-time

Part-time

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* Year training commenced

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* CLINICAL EXPERTISE

	Unsatisfactory				Satisfactory
Demonstrates competency in patient assessment.	Demonstrates competency in patient assessment. Unsatisfactory	Demonstrates competency in patient assessment.	Demonstrates competency in patient assessment.	Demonstrates competency in patient assessment.	Demonstrates competency in patient assessment. Satisfactory	Demonstrates competency in patient assessment.
Patient History and Examination – obtains thorough information.	Patient History and Examination – obtains thorough information. Unsatisfactory	Patient History and Examination – obtains thorough information.	Patient History and Examination – obtains thorough information.	Patient History and Examination – obtains thorough information.	Patient History and Examination – obtains thorough information. Satisfactory	Patient History and Examination – obtains thorough information.
Clinical Decisions and Diagnoses – demonstrates competency.	Clinical Decisions and Diagnoses – demonstrates competency. Unsatisfactory	Clinical Decisions and Diagnoses – demonstrates competency.	Clinical Decisions and Diagnoses – demonstrates competency.	Clinical Decisions and Diagnoses – demonstrates competency.	Clinical Decisions and Diagnoses – demonstrates competency. Satisfactory	Clinical Decisions and Diagnoses – demonstrates competency.
Treatment Management Plan – makes sound decisions about clinical management and checks risks if uncertain about interventions.	Treatment Management Plan – makes sound decisions about clinical management and checks risks if uncertain about interventions. Unsatisfactory	Treatment Management Plan – makes sound decisions about clinical management and checks risks if uncertain about interventions.	Treatment Management Plan – makes sound decisions about clinical management and checks risks if uncertain about interventions.	Treatment Management Plan – makes sound decisions about clinical management and checks risks if uncertain about interventions.	Treatment Management Plan – makes sound decisions about clinical management and checks risks if uncertain about interventions. Satisfactory	Treatment Management Plan – makes sound decisions about clinical management and checks risks if uncertain about interventions.
Procedural Skills.	Procedural Skills. Unsatisfactory	Procedural Skills.	Procedural Skills.	Procedural Skills.	Procedural Skills. Satisfactory	Procedural Skills.

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* PROFESSIONAL QUALITIES

Communication

	Unsatisfactory				Satisfactory
Communication with Patients - educates adequately and informs patients of treatment management plan.	Communication with Patients - educates adequately and informs patients of treatment management plan. Unsatisfactory	Communication with Patients - educates adequately and informs patients of treatment management plan.	Communication with Patients - educates adequately and informs patients of treatment management plan.	Communication with Patients - educates adequately and informs patients of treatment management plan.	Communication with Patients - educates adequately and informs patients of treatment management plan. Satisfactory	Communication with Patients - educates adequately and informs patients of treatment management plan.
Communication with Colleagues – communicates clinical reasoning and intended clinical action.	Communication with Colleagues – communicates clinical reasoning and intended clinical action. Unsatisfactory	Communication with Colleagues – communicates clinical reasoning and intended clinical action.	Communication with Colleagues – communicates clinical reasoning and intended clinical action.	Communication with Colleagues – communicates clinical reasoning and intended clinical action.	Communication with Colleagues – communicates clinical reasoning and intended clinical action. Satisfactory	Communication with Colleagues – communicates clinical reasoning and intended clinical action.
Written Communication – maintains legible records with adequate detail,writes clear precise referral letters.	Written Communication – maintains legible records with adequate detail,writes clear precise referral letters. Unsatisfactory	Written Communication – maintains legible records with adequate detail,writes clear precise referral letters.	Written Communication – maintains legible records with adequate detail,writes clear precise referral letters.	Written Communication – maintains legible records with adequate detail,writes clear precise referral letters.	Written Communication – maintains legible records with adequate detail,writes clear precise referral letters. Satisfactory	Written Communication – maintains legible records with adequate detail,writes clear precise referral letters.

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* Safety and Quality

	Unsatisfactory				Satisfactory	N/A
Optimises safe work practice – follows protocols and procedures.	Optimises safe work practice – follows protocols and procedures. Unsatisfactory	Optimises safe work practice – follows protocols and procedures.	Optimises safe work practice – follows protocols and procedures.	Optimises safe work practice – follows protocols and procedures.	Optimises safe work practice – follows protocols and procedures. Satisfactory	Optimises safe work practice – follows protocols and procedures. N/A
Administers medication and sclerosants safely – according to recommendations.	Administers medication and sclerosants safely – according to recommendations. Unsatisfactory	Administers medication and sclerosants safely – according to recommendations.	Administers medication and sclerosants safely – according to recommendations.	Administers medication and sclerosants safely – according to recommendations.	Administers medication and sclerosants safely – according to recommendations. Satisfactory	Administers medication and sclerosants safely – according to recommendations. N/A

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* Cultural Competency

	Unsatisfactory				Satisfactory
Communicates effectively,treats patient's as individuals and uses knowledge of patient's cultural and religious background in the management, treatment and care of the patient.	Communicates effectively,treats patient's as individuals and uses knowledge of patient's cultural and religious background in the management, treatment and care of the patient. Unsatisfactory	Communicates effectively,treats patient's as individuals and uses knowledge of patient's cultural and religious background in the management, treatment and care of the patient.	Communicates effectively,treats patient's as individuals and uses knowledge of patient's cultural and religious background in the management, treatment and care of the patient.	Communicates effectively,treats patient's as individuals and uses knowledge of patient's cultural and religious background in the management, treatment and care of the patient.	Communicates effectively,treats patient's as individuals and uses knowledge of patient's cultural and religious background in the management, treatment and care of the patient. Satisfactory	Communicates effectively,treats patient's as individuals and uses knowledge of patient's cultural and religious background in the management, treatment and care of the patient.

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* Leadership and Management

	Unsatisfactory				Satisfactory
Balances personal and professional priorities – shows coping skills, asks for help when needed.	Balances personal and professional priorities – shows coping skills, asks for help when needed. Unsatisfactory	Balances personal and professional priorities – shows coping skills, asks for help when needed.	Balances personal and professional priorities – shows coping skills, asks for help when needed.	Balances personal and professional priorities – shows coping skills, asks for help when needed.	Balances personal and professional priorities – shows coping skills, asks for help when needed. Satisfactory	Balances personal and professional priorities – shows coping skills, asks for help when needed.
Reliability and dependability – carries out instruction, fulfills obligations, is punctual to work and tutorials.	Reliability and dependability – carries out instruction, fulfills obligations, is punctual to work and tutorials. Unsatisfactory	Reliability and dependability – carries out instruction, fulfills obligations, is punctual to work and tutorials.	Reliability and dependability – carries out instruction, fulfills obligations, is punctual to work and tutorials.	Reliability and dependability – carries out instruction, fulfills obligations, is punctual to work and tutorials.	Reliability and dependability – carries out instruction, fulfills obligations, is punctual to work and tutorials. Satisfactory	Reliability and dependability – carries out instruction, fulfills obligations, is punctual to work and tutorials.
Initiative and Enthusiasm – self motivates,asks questions of supervisors.	Initiative and Enthusiasm – self motivates,asks questions of supervisors. Unsatisfactory	Initiative and Enthusiasm – self motivates,asks questions of supervisors.	Initiative and Enthusiasm – self motivates,asks questions of supervisors.	Initiative and Enthusiasm – self motivates,asks questions of supervisors.	Initiative and Enthusiasm – self motivates,asks questions of supervisors. Satisfactory	Initiative and Enthusiasm – self motivates,asks questions of supervisors.
Aware of limitations of expertise.	Aware of limitations of expertise. Unsatisfactory	Aware of limitations of expertise.	Aware of limitations of expertise.	Aware of limitations of expertise.	Aware of limitations of expertise. Satisfactory	Aware of limitations of expertise.
Orders case specific investigations, uses healthcare resources appropriately.	Orders case specific investigations, uses healthcare resources appropriately. Unsatisfactory	Orders case specific investigations, uses healthcare resources appropriately.	Orders case specific investigations, uses healthcare resources appropriately.	Orders case specific investigations, uses healthcare resources appropriately.	Orders case specific investigations, uses healthcare resources appropriately. Satisfactory	Orders case specific investigations, uses healthcare resources appropriately.

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* Health Advocacy

	Unsatisfactory				Satisfactory
Encourages patients and communicates to improve and maintain health, and prevent disease.	Encourages patients and communicates to improve and maintain health, and prevent disease. Unsatisfactory	Encourages patients and communicates to improve and maintain health, and prevent disease.	Encourages patients and communicates to improve and maintain health, and prevent disease.	Encourages patients and communicates to improve and maintain health, and prevent disease.	Encourages patients and communicates to improve and maintain health, and prevent disease. Satisfactory	Encourages patients and communicates to improve and maintain health, and prevent disease.

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* Teaching and Learning

	Unsatisfactory				Satisfactory
Takes responsibility for own learning.	Takes responsibility for own learning. Unsatisfactory	Takes responsibility for own learning.	Takes responsibility for own learning.	Takes responsibility for own learning.	Takes responsibility for own learning. Satisfactory	Takes responsibility for own learning.
Delivers meaningful education to patients.	Delivers meaningful education to patients. Unsatisfactory	Delivers meaningful education to patients.	Delivers meaningful education to patients.	Delivers meaningful education to patients.	Delivers meaningful education to patients. Satisfactory	Delivers meaningful education to patients.
Accepts feedback and guidance and shows commitment to improvement.	Accepts feedback and guidance and shows commitment to improvement. Unsatisfactory	Accepts feedback and guidance and shows commitment to improvement.	Accepts feedback and guidance and shows commitment to improvement.	Accepts feedback and guidance and shows commitment to improvement.	Accepts feedback and guidance and shows commitment to improvement. Satisfactory	Accepts feedback and guidance and shows commitment to improvement.

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* Ethics

	Unsatisfactory				Satisfactory
Shows understanding and judgment of ethical issues.	Shows understanding and judgment of ethical issues. Unsatisfactory	Shows understanding and judgment of ethical issues.	Shows understanding and judgment of ethical issues.	Shows understanding and judgment of ethical issues.	Shows understanding and judgment of ethical issues. Satisfactory	Shows understanding and judgment of ethical issues.
Complies with policies and legal legislation.	Complies with policies and legal legislation. Unsatisfactory	Complies with policies and legal legislation.	Complies with policies and legal legislation.	Complies with policies and legal legislation.	Complies with policies and legal legislation. Satisfactory	Complies with policies and legal legislation.

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* In your opinion, what are main strengths of this trainee's performance?

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* In your opinion, what areas of this trainee's performance require further development.

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* The overall performance of the Trainee in the previous six months has been:

Unsatisfactory

Satisfactory

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* * If unsatisfactory a performance improvement form is required and the relevant DOT is to be notified. Has the DOT been notified?

Yes

No

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* Print a hard copy of the completed form and confirm with a signature below.

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* Email completed SITA form as PDF to the SOT and Education Officer.

The Trainee does not see the completed form.

OK