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Preceptor Survey of Student

Student Name

Select Student

Evaluation Period

Externship Dates

Preceptor Name

Instructions


Please evaluate the student based on observed clinical performance during this rotation. Circle the response that best reflects the student’s performance. ADOM standard for a passing grade is 83% and above.


Rating Scale


5 = Exceeds Expectations (96-100%)


4 = Above Average (90-95%)


3 = Meets Expectations (83-89%)


2 = Needs Improvement (77-82%)


1 = Unsatisfactory (76% or below)


N/A = Not Applicable

Demonstrates professionalism and ethical conduct
Arrives prepared and punctual
Demonstrates appropriate patient communication
Maintains patient confidentiality (HIPAA compliance)
Demonstrates safe patient care practices
Demonstrates appropriate ergonomic/body mechanics awareness
Follows scanning protocols appropriately
Demonstrates proper transducer handling and equipment use
Demonstrates knowledge of anatomy and physiology
Demonstrates critical thinking/problem solving skills
Accepts feedback professionally
Demonstrates initiative and willingness to learn
Demonstrates appropriate image acquisition skills
Demonstrates effective teamwork with staff
Demonstrates readiness for increasing clinical responsibility
Overall Clinical Performance:
Would you consider hiring this student upon graduation?

Thank you for supporting the clinical education of ADOM Academy students. Your feedback is valuable in helping us maintain educational excellence, improve student outcomes, and strengthen the quality of our clinical training program. We sincerely appreciate your time, mentorship, and partnership.

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