Y1 Mentor Evaluation

Student Name

Name of Mentor

Date

Note to student: Please help us evaluate the mentor portion of the clinical mentor program. Be specific about strengths and weaknesses in your comments. Feel free to discuss any comments that you do not wish to put in writing with a member of the Doctoring Staff. THANK YOU! Your comments will be confidential and NOT shared with your mentor.

Using the scale below, select the appropriate number for each statement:

1 = Strongly Disagree
2 = Disagree
3 = Undecided
4 = Agree
5 = Strongly Agree

MENTOR'S TEACHING STYLE:
	Strongly Disagree Strongly Agree
	1	2	3	4	5
Mentor is an excellent role model.
Mentor is enthusiastic about teaching.
Mentor encouraged me to formulate diagnoses.
Mentor/nurse selected patients for me to see.
Mentor assigned learning issues/articles to read.
Mentor encouraged me to spend time with other staff in the office.
Mentor has exemplary noncognitive (professional) behaviors.
Comments on Mentor's Teaching Style:
LEARNING/PRACTICE ENVIRONMENT:
	Strongly Disagree Strongly Agree
	1	2	3	4	5
The average number of patients for whom I provided hands-on care each visit was:
The number of patients for whom I provided hands-on care each visit was appropriate for me.
I felt comfortable with the amount of responsibility given to me.
Comments on the learning/practice environment:
EVALUATION AND FEEDBACK
	Strongly Disagree Strongly Agree
	1	2	3	4	5
Mentor alerted me to clinical insights, data or cues I had missed.
Mentor provided informal feedback at the end of each clinical session.
Mentor provided formal feedback at the end of the year.
Comments on Evaluation & Feedback:
IN GENERAL ...
	Poor 1	Fair 2	Average 3	Good 4	Excellent 5
Overall educational value of the clinical mentor program.
Overall rating of mentor
Should we use this physician as a clinical mentor next year?	Yes No
Comments/Suggestions on how to improve the mentor clinical experience program:

MENTOR OF THE YEAR NOMINATION ...

If you wish to nominate your physician for this award, please share your reasons in the space provided.

Page last updated Monday May 12, 2008