Lampiran 3 [PPSP/MD/ELEKTIF_4/CP1/L3]

School of Medical Sciences, USM Health Campus Kelantan,16150 Malaysia

To the supervisor of medical students from USM, Health Campus Dear Supervisor, Thank you very much for supervising our student during her / his elective at your institution. We would be most grateful if you could fill out the attached assessment form. Please kindly hand the student the completed form. The student will bring with her/ him to the academic office of School of Medical Sciences USM. Yours sincerely Elective Secretariat Academic Office School of Medical Sciences USM, Health campus 16150 Kubang Kerian Kelantan, Malaysia Phone:609-7676045 / 6046 Fax: 609-7653370 Email: ismaildr@kb.usm.my reeny@kck.usm.my

ASSESSMENT CLINICAL ELECTIVE FORM

Dear Supervisor Below are the statements addressing the performance of a student from school of Medical Sciences USM when working under your supervision. Name of student:……………………………………………………….. Date: Please kindly circle the number for each statement based on the scale given: Very good – 4 Good – 3 Satisfactory – 2 Unsatisfactory - 1

The statements Scale

How well the student prepared for the programme conducted under your supervision with respect to basic science knowledge?

4 3 2 1

How well the student prepared for the programme conducted under your supervision with respect to clinical knowledge?

4 3 2 1

How well the student prepared for the programme conducted under your supervision with respect to communication skill?

4 3 2 1

How well the student prepared for the programme conducted under your supervision with respect to practical skill?

4 3 2 1

How did the student progress when working under your supervision with respect to acquisition of relevant knowledge?

4 3 2 1

How did the student progress when working under your supervision with respect to participation in department activities?

4 3 2 1

How did the student progress when working under your supervision with respect to issues in medical ethics?

4 3 2 1

How did the student progress when working under your supervision with respect to punctuality and attendances?

4 3 2 1

How was the student’s attitude when interacting with patients, faculty and colleagues?

4 3 2 1

What is your overall judgment on the student’s performance?

4 3 2 1

Additional comments (if any) ……………………………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………………

Supervisor’s name: Signature & official stamp:

Thank you very much for your cooperation.

Fn/elektif/PPSPassessment/nrra/2010