ࡱ> e lbjbjJJ ?v(_b(_b 668D:,fpfffffUUUfffffff$ hj>fU@UUU>f66ffSf!!!U^6Rfff!Uf!!b0^$"df d"^TaVfif0faokokdokd|UU!UUUUU>f>f UUUfUUUUokUUUUUUUUUB : ST SCRUB EVALUATION FORM to be completed once a Week. STUDENT MUST SUBMIT ONE EVALUATION FORM TO THEIR CLINICAL INSTRUCTOR. Clinical Instructor, complete a short form evaluation; a Final Scrub Role Evaluation Form will be used during the last two weeks of the semester. Name__________________________ Date_________ Facility __________Evaluator Signature__________________ Meets Standards/ Meets Expectations 4 Standards are defined as The Basic Principles Understands Standards; Needs More Practice 3 of Aseptic and Operating Room Care as defined by AST and States Standards; Unacceptable Practice 2 AORN Standards. Standard Operating Room Technique. Inserviced On Standards; Unacceptable Practice 1 Points Points 1 2 3 4 N/A Wt. Poss. Student Comments STERILE TECHNIQUE: Demonstrates surgical conscience; Excels if catches breaks for others/guards assertively. 520Demonstrates knowledge of procedure, Excels if they teach you something.312 or N/ADemonstrates knowledge of instruments, Excels if they know rare inst.520 or N/ADemonstrates Safe Handling and passing of sharps and instruments Excels if they prevent an injury.520 or N/ADemonstrates anticipation, Excels if anticipates an unusual situation. 312 or N/ADemonstrates organization, Keeps mayo organized. Excels inst. kept clean.416 or N/AGrade : 90100% (A) 80-89%(B) 70-79% (C) - Satisfactory [ 60 -69% (D) Less than 60 (F) ] Unacceptable(Divide Student Total by Possible Total) ____/ 100PROFESSIONAL POINTS FOR DAY: No 0Some 1Mostly 3Yes 5Max ScoreScoreIf meets criteria to your satisfaction=5 score. Comments:Punctual On time (Arrival, return Lunch, etc.) prepared for case. Asks Questions at appropriate time. 5Initiative Open case/performs role without prompting. 5Communication -Politeness/ Respect Courtesynotifies whereabouts.5ReliableAccountable- Does the right thing. 5Effective - Attentive- Remains calm and focused. 5Accepts feedback-Responsive to critique. Does not explain self. 5Grade : 90100% (A) 80-89%(B) 70-79% (C) - Satisfactory [ 60 -69% (D) Less than 60 (F) ] Unacceptable(Divide Student Total by Possible Total) _____/30Grade  IF YOU NEED ROOM FOR ADDITIONAL COMMENTS ON STUDENTS PERFORMANCE-SEE BACK. Date Reviewed _________________Student Signature_________________________________ Instructor or Preceptor Signature___________________________      Gulf Coast State College Reviewed 10/31//2017 Optional: If you would like to review the program objectives regarding the expectations for clinical instruction or give the faculty some feedback or a message: Evaluation of Student Preparation of Clinical Site: 1 2 3 4 Comments Faculty members provide adequate orientation for students and are available when needed or requested for direction and student concerns.Students are adequately prepared (could use some help with______________________)I as a preceptor provide guidance and direction while allowing students independence to setup cases using the universal case setup as approved. I as a preceptor provide direct observation and supervision of all student activities for direct patient care. I am consistent in my evaluation of all students according to the students experience level and role objectives for the case. PHYSICIAN. I observed that the physician provided effective communication and was willing to facilitate student learning. 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