CLINICAL EXPERIENCE REPORTING FORM CR-2

The Pennsylvania AHEC, in partnership with your school, is seeking to help meet the primary care needs of our communities and to make health careers training a more valuable experience. Results from this survey will be used to support these goals. All survey responses are confidential. Data will only be used within the AHEC program and never for commercial purposes.

Date of Completion: October 18 2017

Your Name


Academic/Training Year Undergraduate - Year 1
Undergraduate - Year 2
Undergraduate - Year 3
Undergraduate - Year 4
Undergraduate - Year 5
Graduate - Year 1
Graduate - Year 2
Graduate - Year 3
Graduate - Year 4
Graduate - Year 5
Graduate - Year 6
Graduate - Year 7
Residency - Year 1
Residency - Year 2
Residency - Year 3
Residency - Year 4
Fellowship - Year 1
Fellowship - Year 2
Fellowship - Year 3
Internship - Year 1
Internship - Year 2
Non-Degree Training Program - Year 1
Non-Degree Training Program - Year 2
Training Category: Group

Student (Enrollee)
Fellow
Resident
Faculty
Practicing Professional

Full-Time
Part-Time
On Leave of Absence

Under 20 Years
20-29 Years
30-39 Years
40-49 Years
50-59 Years
60 Years or Older

What is Your Discipline/Specialty? Chiropractic
Family Medicine
General Internal Medicine
General Pediatrics
General Preventative Medicine
Obstetrics/Gynecology
Pharmacy
Podiatry
Psychiatry
Public Health
Physician Assistant
General Dentistry
Dental Hygiene
Dental Assistant
Public Health Dentistry
Nurse Administrator
Nurse Anesthetist
Nurse Midwife
Nurse Practitioner (NP)
LPN
MSN - other adv. nurse specialists
Registered Nurse
Clinical Psychology
Clinical Social Work
Physical Therapy


What is the name of the facility where your rotation took place?

What is the name(s) of your preceptor(s) responsible for this rotation?
The clinical experience (rotation) you just completed could best be considered: Family Medicine
General Internal Medicine
General Pediatrics
General Surgery
Psychiatry
OB/GYN
General Dentistry
Nursing
Pharmacy
What were the start and end dates of this clinical experience (rotation)? Start Date:
 

End Date:
 
How much clinical time did you spend during this training/clinical experience? (If less than one day, enter "1")

Did you complete this program (rotation)?  Yes   |   No

Do you intend to practice in Pennsylvania?  Yes   |   No

Do you intend to practice in a Primary Care Setting?  Yes   |   No

Do you intend to practice in a Medically Underserved Area?  Yes   |   No

\Do you intend to practice in a Rural Area?  Yes   |   No

Please rate the clinical experience (rotation) you just completed
Achievement of the learning objectives intended or stated for this experience
Extremely Dissatisfied
Dissatisfied
Neutral
Satisfied
Extremely Satisfied
Does Not Apply

Achievement of my personal learning objectives
Extremely Dissatisfied
Dissatisfied
Neutral
Satisfied
Extremely Satisfied
Does Not Apply

Accessibility of on-site learning resources
(internet, tutorials, etc.)
Extremely Dissatisfied
Dissatisfied
Neutral
Satisfied
Extremely Satisfied
Does Not Apply

Accessibility of preceptor
Extremely Dissatisfied
Dissatisfied
Neutral
Satisfied
Extremely Satisfied
Does Not Apply

Opportunity to deliver hands-on patient care
Extremely Dissatisfied
Dissatisfied
Neutral
Satisfied
Extremely Satisfied
Does Not Apply

Accessibility of internet and other learning resources from my housing location
Extremely Dissatisfied
Dissatisfied
Neutral
Satisfied
Extremely Satisfied
Does Not Apply

Quality/Condition/Safety of housing
Extremely Dissatisfied
Dissatisfied
Neutral
Satisfied
Extremely Satisfied
Does Not Apply

Quality of community lifestyle
(resources / culture / educational / social / entertainment)
Extremely Dissatisfied
Dissatisfied
Neutral
Satisfied
Extremely Satisfied
Does Not Apply

If you can see this, leave the following fields blank


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