NEPA-AHEC - Student Experiences

Clinical Experience Reporting Form (Exit) CR - 2 For GCSOM Students Only

The Pennsylvania AHEC, in partnership with GCSOM, is seeking to help meet the primary care needs of our communities and to make health careers training a more valuable experience. Results from this survey will be used to support these goals. All survey responses are confidential. Data will only be used within the AHEC program and TCMC; never for commercial purposes.

Please answer each item as completely as possible.

Date Completed? (Month/Day/Year)

Your name? (Last, First, Middle, Maiden)

Academic/Training Year

Do you intend to practice in Pennsylvania?

Do you intend to practice in a Primary Care Setting?

Do you intend to practice in a Medically Underserved Area?

Do you intend to practice in a Rural Area?

Please complete an evaluation for each Primary Care rotation:
Family Medicine • Internal Medicine • OB/GYN • Pediatrics • Psychiatry •

What is the name of your preceptor responsible for Family Medicine?

Preceptor Name (first last)

What is the name of the facility where your rotation took place?

Name of the facility:

Please rate the Family Medicine clinical experience (rotation) you just completed with respect to the following:

Achievement of the learning objectives intended or stated for this experience

Achievement of my personal learning objectives

Accessibility of on-site learning resources (Internet, tutorials, etc.)

Accessibility of preceptor

Opportunity to deliver hands-on patient care

Comments

What is the name of your preceptor responsible for Internal Medicine?

Preceptor Name (first last)

What is the name of the facility where your rotation took place?

Name of the facility:

Please rate the Internal Medicine clinical experience (rotation) you just completed with respect to the following:

Achievement of the learning objectives intended or stated for this experience

Achievement of my personal learning objectives

Accessibility of on-site learning resources (Internet, tutorials, etc.)

Accessibility of preceptor

Opportunity to deliver hands-on patient care

Comments

What is the name of your preceptor responsible for OB/GYN?

Preceptor Name (first last)

What is the name of the facility where your rotation took place?

Name of the facility:

Please rate the OB/GYN clinical experience (rotation) you just completed with respect to the following:

Achievement of the learning objectives intended or stated for this experience

Achievement of my personal learning objectives

Accessibility of on-site learning resources (Internet, tutorials, etc.)

Accessibility of preceptor

Opportunity to deliver hands-on patient care

Comments

What is the name of your preceptor responsible for Pediatrics?

Preceptor Name (first last)

What is the name of the facility where your rotation took place?

Name of the facility:

Please rate the Pediatrics clinical experience (rotation) you just completed with respect to the following:

Achievement of the learning objectives intended or stated for this experience

Achievement of my personal learning objectives

Accessibility of on-site learning resources (Internet, tutorials, etc.)

Accessibility of preceptor

Opportunity to deliver hands-on patient care

Comments

What is the name of your preceptor responsible for Psychiatry?

Preceptor Name (first last)

What is the name of the facility where your rotation took place?

Name of the facility:

Please rate the Psychiatry clinical experience (rotation) you just completed with respect to the following:

Achievement of the learning objectives intended or stated for this experience

Achievement of my personal learning objectives

Accessibility of on-site learning resources (Internet, tutorials, etc.)

Accessibility of preceptor

Opportunity to deliver hands-on patient care

Comments

What is the name of your preceptor responsible for Surgery (Part 1)?

Preceptor Name (first last)

What is the name of the facility where your rotation took place?

Name of the facility:

Please rate the Surgery clinical experience (rotation) you just completed with respect to the following:

Achievement of the learning objectives intended or stated for this experience

Achievement of my personal learning objectives

Accessibility of on-site learning resources (Internet, tutorials, etc.)

Accessibility of preceptor

Opportunity to deliver hands-on patient care

Comments

What is your preferred email address?(Required for online submission)

Enter the below form code (all numbers)

164 Scranton Carbondale Highway
Archbald, PA 18403

(570) 209-9644

northeastpaahec@gmail.com

info@nepa-ahec.org

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