MORGAN STATE UNIVERSITY

Program in Medical Technology

Interim Evaluation for Clinical Rotations

            Student’s Name ____________________________

            Evaluation Date ____________________________

            Affiliate’s Name _____________________________

            Circle Rotation  1   2   3   4

            Laboratory Area ____________________________

Please rank this student on a scale of 1-5.  A rank of 1 would indicate that standards are not met and a rank of 5 would indicate that the student exceeds standards.

INTEREST________________________

RESPONSIBILITY__________________________

ADHERENCE TO SAFETY STANDARDS __________________

KNOWLEDGE ___________________

TECHNIQUE _____________________

PROFESSIONAL BEHAVIOR _____________________________

Number of late occurrences ______________________

Comments ____________________________________

Evaluator ______________________Title________________Date___________

                    (signature)

Reviewed by _______________________ Date_______________

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