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Student Evaluation of the Clinical Experience and Supervision

Please evaluate your clinical experience and clinic supervisor, by answering the following questions.


Clinic and Student Information

Your First Name:
Your Last Name:
Last five digits of your Social Security Number:
Clinic Day:
Clinic Location:
Supervisor's Name:

1.     Clinical opportunities match the internship objectives for the phase.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

2.     Clinical experiences model ethical and professional behavior.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

3.     Clinic safety standards are understood and followed.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

4.     Clinical experiences assisted me in understanding theoretical principles.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

5.     This supervisor encourages respect for interns and patients of diverse backgrounds.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

6.     This supervisor assisted me in the developing assessment and diagnostic skills.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

7.     This supervisor assisted me with treatment strategy and planning.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

8.     This supervisor helped me with acu/moxa techniques and/or other clinical skills.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

9.     This supervisor helped me with herbal diagnosis and formula selection.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

10.   This supervisor helped me with adding TCM nutrition to patient care.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

11.   This supervisor gives feedback on the quality of SOAP notes and case records.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

12.   This supervisor helps interns respond to patient's ethical and emotional dilemmas.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

13.   This supervisor motivates and encourages interns as they progress through phases.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

14.   Clinic experiences allowed me to apply various therapeutic modalities.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

15.   Clinic experiences provided me with a variety of health care problems.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

16.   I have improved my interviewing and communication skills.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

17.   I am given responsibility for patients commensurate with my abilities.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

18.   Feedback on my overall performance provides direction for professional development.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

19.   Feedback on my clinical ability provides direction for skills development.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable

20.   Criteria were fairly applied in evaluating performance.

Strongly agree, superior
Agree good
Somewhat disagree
Disagree, needs improvement/growth area
Not Applicable