GIMSPP Preceptor Evaluation of Student

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Your First Name *
Your Last Name *

Evaluation of the Student

Student's Name *
Student's School *
1. The student behaved professionally with staff members and patients.
2. The student was on time for required activities.
3. The student took his/her responsibilities seriously.
4. My student and I established realistic goals from the onset of the preceptorship.
5. We made periodic reassessments of his/her goals and progress toward achieving them.
6. The student was able to perform examinations appropriate to his/her level of training.
7. The student's knowledge base and performance were satisfactory for his/her level of training.
8. The student took comments and suggestions as constructive feedback.
9. The student made progress in understanding what a future as an internist would be.
10. I feel this student would make a good internist.
11. I am comfortable awarding academic credit to this student (if applicable).
12. I would describe this student's overall performance as:
13. This evaluation form may be shared with the student. *
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Evaluation of the Program

14. I enjoyed this preceptorship experience
15. I will continue to mentor students
Comments on Program (900 character limit): *
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Physician Recommendation

As the GIMSPP Program grows, we have a greater need for more Internists to volunteer as preceptors. If you have colleagues or friends who you think might be interested in being preceptors, please submit their names and phone numbers below. Thank you!
Physician Name
Physician Phone
Physician Name
Physician Phone
Thank you for your help in building the future of Internal Medicine by being a preceptor in the General Internal Medicine Statewide Preceptorship Program. Please fill out the evaluation form below. All information provided will be kept confidential unless otherwise authorized by you.


GIMSPP Business Office
401 W. 15th Street, Suite #100
Austin, TX, 78701-1680
Toll free phone: (866) 2-GIMSPP
Fax: (512) 370-1635
Rebecca Lawson
Program Manager


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