This form should be completed to document directly observed behaviors from a clinical encounter.  Focus on behaviors and do not adjust the assessment based on the student's level of training. You only need to comment on areas you directly observed. The purpose of this form is to provide "just-in-time" feedback to the student so that they continue their growth towards becoming a competent provider.  We are not asking you to provide an overall assessment or grade.  Thank You!

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* 1. Student Name

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* 2. Evaluator Name

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* 3. Clerkship

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* 4. Please select your faculty role

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* 5. Please select the acuity of the patient

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* 6. Please select the clinical setting of the encounter

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* 7. Please select all descriptors that apply to this student's professional formation

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* 8. Which portions of the encounter or which clinical skill did you directly observe (select all that apply)?

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