Medical Student and Clerk Rotation Evaluation

1. Rotation Information

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* 1. Please fill out the following information:

Name:

Preceptor:

Community:

Clinic/Hospital

Core or Elective Rotation

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* 2. Rotation Dates:

Start Date:

Date

Finish Date:

Date

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* 3. University:

McMaster University

University of Western Ontario

University of Toronto

Queen's University

University of Ottawa

Northern Ontario School of Medicine

Other (please specify):

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* 4. Rotation:

Allergist

Anesthesia

Cardiology

Dermatology

Emergency Medicine

Endocrinology

Family Medicine

Gastroenterology

General Surgery

Geriatrics / Gerontology

Hospitalises

Infectous Disease

Internal Medicine

Nephrology

Neurology

Neurosurgery

Obstetrcis/Gyn.

Oncology

Opthalmogloy

Ortho Surgery

Otolaryngologist

Paediatric Neurology

Paediatrics

Pathology

Physical Medicine, Rehab

Plastic Surgery

Psychiatry

Radiology

Respirartory Medicine

Rheumatology

Surgery

Thoracic Surgery

Urology

Vascular Surgery

Other (please specify):

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* 5. Level of Training

Medical Student

Clerk

Resident

Other

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* 6. Year in Program

First

Second

Third

Fourth

Other

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* 7. Which community choice did you receive?

First Choice

Second Choice

Third Choice

Other

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* 8. Please identify your main reason(s) for participating in a ROMP-facilitated rotation:

Mandatory Rural Rotation

Community-Specific (wanted experience in a specific community, close to home, etc.)

Preceptor-Specific (wanted to work with a specific physician)

Recommended by peers/others

Received Information from Info Session/Website

Other (please specify):