Clinical Site Visit Evaluation
Your Full Name
*
First Name
Last Name
Email
*
example@example.com
Date of Visit
*
-
Month
-
Day
Year
Date
This form is being filled out by someone in the role of:
*
Clinical Coordinator
Clinical Instructor
Program Evalutating Site For:
*
Please Select
Surgical Technology
Diagnostic Medical Sonography
Medical Dosimetry
Paramedic/EMT
Radiography
Radiation Therapy
Quarter/Semester
*
Clinical Site
*
How many students at this site?
*
If more than 12, please submit form twice.
CST Clinical Preceptor of this site
*
For each question, please check off the appropriate box:
*
Yes
No
N/A
Was the facility clean?
Was the facility accessible (parking, safety, proximity to public transportation, etc,)?
Was the equipment at the site adequate and updated?
Were the technologists receptive to the site visit?
Were the technologists receptive to the students?
Did the student/s appear to be part of the team?
Did the site meet your expectations?
Were the students and clinical staff complying with the supervision requirements?
*
Yes
No
N/A
If no, please explain:
*
Overall impression of the clinical site (please explain):
*
Evaluation of Students at Site
Full Name (Student #1)
*
First Name
Last Name
In attendance?
*
Yes
No
Observation/Evaluation
*
Full Name (Student #2)
First Name
Last Name
In attendance?
Yes
No
Observation/Evaluation
Full Name (Student #3)
First Name
Last Name
In attendance?
Yes
No
Observation/Evaluation
Full Name (Student #4)
First Name
Last Name
In attendance?
Yes
No
Observation/Evaluation
Full Name (Student #5)
First Name
Last Name
In attendance?
Yes
No
Observation/Evaluation
Full Name (Student #6)
First Name
Last Name
In attendance?
Yes
No
Observation/Evaluation
Full Name (Student #7)
First Name
Last Name
In attendance?
Yes
No
Observation/Evaluation
Full Name (Student #8)
First Name
Last Name
In attendance?
Yes
No
Observation/Evaluation
Full Name (Student #9)
First Name
Last Name
In attendance?
Yes
No
Observation/Evaluation
Full Name (Student #10)
First Name
Last Name
In attendance?
Yes
No
Observation/Evaluation
Full Name (Student #11)
First Name
Last Name
In attendance?
Yes
No
Observation/Evaluation
Full Name (Student #12)
First Name
Last Name
In attendance?
Yes
No
Observation/Evaluation
Signature
*
Submit
Should be Empty: