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Center for Health Sciences
Rural Medical Education
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Community Hospital Clerkship

Checklist

Course requirements listed below are due the end of the rotation and must be submit within 7 days of completing this rotation.  If all items are not received by the 7th, points will be deducted from the final grade.  You may print this out for your own record.

*Denotes required fields

 
*First Name *Email
*Phone *Alternate Phone/Pager
(Enter your 10 digit number without other characters; i.e. no dashes, no parenthesis).
 

  Check yes if completed
*CH 1 Student Performance Evaluation Form Yes No
*CH 2 Student Performance Evaluation Form Yes No
*CH 1 Student Site Evaluation Form Yes No
*CH 2 Student Site Evaluation Form Yes No
*Video Lecture Evaluation #1 (CH 1 - Due after 1st month) Yes No
*Video Lecture Evaluation #2 (CH 1 - Due after 1st month) Yes No
*Video Lecture Evaluation #3 (CH 2 - Due after 2nd month) Yes No
*Video Lecture Evaluation #4 (CH 2 - Due after 2nd month) Yes No
*Procedure/Skills Card (CH 1 - Due after 1st month) Yes No
*Procedure/Skills Card (CH 2 - Due after 2nd month) Yes No

 

Notes: