For additional information, please contact: Anslee Boozer, Pediatric Preceptorship Program Coordinator 401 West 15th Street, Suite 682 Austin, Texas 78701 (512) 370-1563 Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20202021202220232024 Preceptor * Student * Please complete the following items by selecting the response that best describes your experience with the preceptor being evaluated. Use the following scale. 1. I enjoyed my preceptorship experience * - Select -Strongly DisagreeDisagreeNeutralAgreeStrongly Agree 2. I would recommend the program to other students * - Select -Strongly DisagreeDisagreeNeutralAgreeStrongly Agree 3. I would recommend my preceptor to other students * - Select -Strongly DisagreeDisagreeNeutralAgreeStrongly Agree 4. My preceptor and I established goals at the outset of the program * - Select -Strongly DisagreeDisagreeNeutralAgreeStrongly Agree 5. My preceptor gave constructive feedback about my performance during the month * - Select -Strongly DisagreeDisagreeNeutralAgreeStrongly Agree 6. My preceptor made adequate time for teaching/learning sessions * - Select -Strongly DisagreeDisagreeNeutralAgreeStrongly Agree 7. My preceptor provided me with the amount of responsibility I thought was appropriate * - Select -Strongly DisagreeDisagreeNeutralAgreeStrongly Agree 8. My preceptor seemed to enjoy teaching and having me in his/her office * - Select -Strongly DisagreeDisagreeNeutralAgreeStrongly Agree 9. My preceptor made my position as a medical student clear to the patient * - Select -Strongly DisagreeDisagreeNeutralAgreeStrongly Agree 10. My preceptor selected appropriate patients for me to interact with. * - Select -Strongly DisagreeDisagreeNeutralAgreeStrongly Agree 11. I gained useful information about office management procedures and office organization * - Select -Strongly DisagreeDisagreeNeutralAgreeStrongly Agree 12. I felt comfortable during my preceptor experience * - Select -Strongly DisagreeDisagreeNeutralAgreeStrongly Agree 13. I gained insight and experience with the community health resources available to my preceptor * - Select -Strongly DisagreeDisagreeNeutralAgreeStrongly Agree 14. My preceptor demonstrated a good balance of personal and professional life * - Select -Strongly DisagreeDisagreeNeutralAgreeStrongly Agree 15. I could see that my preceptor was involved in community medical activities * - Select -Strongly DisagreeDisagreeNeutralAgreeStrongly Agree 16. As a result of the preceptorship experience, I am more likely to enter pediatrics * - Select -Strongly DisagreeDisagreeNeutralAgreeStrongly Agree The things I found most useful about the preceptorship were * The things I found least useful about the preceptorship were * Leave this field blank
