Military-Medical Faculty,
Division of Studies in English-Language
1 Hallera Sq., 90-647 Lodz, Poland
HOSPITAL NAME & ADDRESS
______________________________________________________________________________
______________________________________________________________________________
Clinical Evaluation Form
(4- year MD program/6-year MD Program)
Student’s name_______________ Index no._______________ Year____________
Rotation ___________________________________________________
Date of rotation: from __________ to ____________
No. of weeks/hours_____________
Department_________________________________________________
Instructions
Circle the most appropriate number for each question that indicates your evaluation of the student using the following values:
N – not observed 1 – poor 2 – average 3 – good 4 – outstanding
1. Knowledge (ability to integrate theoretical knowledge into clinical practice) N 1 2 3 4
2. History (preciseness and comprehensiveness of information) N 1 2 3 4
3. Physical examination (thoroughness in gathering information) N 1 2 3 4
4. Diagnostic Acumen (developing an appropriate diagnosis) N 1 2 3 4
5. Record keeping (accurately preparing professional write ups) N 1 2 3 4
6. Relationship with Faculty and Staff N 1 2 3 4
7. Relationship with fellow students N 1 2 3 4
8. Relationship with patients (communication skills and attitude) N 1 2 3 4
9. Educational activities (attendance at rounds, lectures, conferences) N 1 2 3 4
10. Clinical presentations (case presentations, progress notes) N. 1 2 3 4
11. Handling of criticism N 1 2 3 4
12. AVERAGE N 1 2 3 4
Case presentation: __________
Evaluator: ________________________ Evaluator : ____________________________
(Signature and Stamp) (Printed Name and Title)
Program Director _________________ Program Director __________________________
(Signature and Stamp) (Printed Name and Title)
Was this evaluation reviewed with the student ? Yes/ No Student: _________ Date: ______
(Signature)
Final Grade for Rotation _________ according to the grading scale* binding in the Medical University of Lodz.
*5.0 – excellent;
4.5 – very good;
4.0 – good;
3.5 – satisfactory;
3.0 – sufficient;
2.0 – failed.
PrincipAl Medical School
Military-Medical Faculty,
Division of Studies in English-Language
1 Hallera Sq., 90-647 Lodz, Poland
HOSPITAL NAME & ADDRESS
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Clinical Evaluation Form
(4- year MD program/6-year MD Program)
Student’s name________________ Index no.___________________
State the STRENGTHS of the student during rotations __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
State the WEAKNESSES of the student during the rotation __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please fill in the form legibly | 
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