Student Evaluation

Hidden

Preceptor Tracking Number

Student Name*

First Last

Doctor Name*

First Last

1. Has the student been prompt and present for all assigned hours?*

Yes
No

2. Does the student demonstrate initiative and willingness to learn?*

Yes
No

3. Has the student demonstrated progress in all areas of responsibility?*

Yes
No

4. Does the student accept and successfully complete all assigned tasks?*

Yes
No

Please rate the student and their overall performance while in your office:*

A - Excellent
B - Above Average
C - Average
D - Below Average
E - Unsatisfactory

What do you feel are the strengths of this student intern?*

Click (+) to ADD additional lines.

Strength	Examples

What areas do you feel the student intern has the greatest opportunity for improvement?*

Click (+) to ADD additional lines.

Area	Examples

Comments

Signature*

I, the undersigned, formally apply to participate in the Doctor of Chiropractic Preceptorship Program with Cleveland University-Kansas City. I have read, understand, and agree to comply with the program’s established guidelines and fulfill all responsibilities. By signing below, I certify that I do not currently have any unresolved licensing board disciplinary actions against my license. If during the course of hosting a preceptor, a licensing board action arises, I will immediately notify Cleveland University Kansas City. I further agree to hold harmless Cleveland University-Kansas City, the Board of Trustees, Administration, Faculty and Employees, and the student assigned to me, in any dispute or action arising from diagnostic or treatment procedures occurring in my office.

Today's Date*

Preceptorship Program
Student Evaluation

STEP: Doctor’s Evaluation of the student

Preceptorship Program Student Evaluation

STEP: Doctor’s Evaluation of the student

Preceptorship Program
Student Evaluation