Practicum Preceptor’s Evaluation Form

Practicum Preceptor Name*

First Last

Student Name*

First Last

The information below will be shared with the student and his/her academic advisor. Please provide specific and constructive feedback.

I. Objectives

Please review practicum objectives described in the practicum proposal or as redefined over the course of the practicum. Based on your knowledge of the student’s activities, how well did the student meet the practicum objectives?*

Above expectations
Fully
Partially
Not at all

Comments:*

II. Process

Please rate the student’s professional performance for each category below.

Time management and follow through (sets priorities and reasonable deadlines, completes tasks on time, fulfills commitment to others).*

Excellent
Satisfactory
Needs work
Insufficient

Time management comments*

Communication (verbal and written, listening skills, asks for and gives feedback).*

Excellent
Satisfactory
Needs work
Insufficient

Communication comments*

Critical and Strategic Thinking (assesses information to make informed decisions; sees the big picture and understands how actions fit into a plan; problem solves).*

Excellent
Satisfactory
Needs work
Insufficient

Critical and strategic thinking comments*

Do you have any additional feedback to provide to the student?

III. Departmental Support and Program

Had you previously served as a Practicum Preceptor for the Department of Epidemiology?*

Yes
No

Would you be willing to serve as a Practicum Preceptor in the future?*

Yes
No

Comments:

What aspects of the practicum program were beneficial to you as a practicum preceptor?*

What aspects of the practicum program would you like to change? Please include specific suggestions for improving the practicum program.*

By checking this box you are applying your signature.*

Signed

Date Signed*

Complete the form and submit it.

After completing this form please notify the student that you submitted it. Thank you.

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