Learners Feedback

Please use this form to provide feedback on the learner's performance.

Learners Name *

Hospital Site *

North York General
Unity Health (St Michael's)

Date *

Staff Physician *

Types of Surgery *

Medical Expert *

	Fails to meet expectations	Weakness	Meets expectations	Sometimes exceeds expectations	Consistently exceeds expectations	Not applicable
Knowledge	Fails to meet expectationsKnowledge Fails to meet expectations	WeaknessKnowledge Weakness	Meets expectationsKnowledge Meets expectations	Sometimes exceeds expectationsKnowledge Sometimes exceeds expectations	Consistently exceeds expectationsKnowledge Consistently exceeds expectations	Not applicableKnowledge Not applicable
Pre-operative assessments and anaesthetic plan	Fails to meet expectationsPre-operative assessments and anaesthetic plan Fails to meet expectations	WeaknessPre-operative assessments and anaesthetic plan Weakness	Meets expectationsPre-operative assessments and anaesthetic plan Meets expectations	Sometimes exceeds expectationsPre-operative assessments and anaesthetic plan Sometimes exceeds expectations	Consistently exceeds expectationsPre-operative assessments and anaesthetic plan Consistently exceeds expectations	Not applicablePre-operative assessments and anaesthetic plan Not applicable
Judgement, critical thinking and decision making	Fails to meet expectationsJudgement, critical thinking and decision making Fails to meet expectations	WeaknessJudgement, critical thinking and decision making Weakness	Meets expectationsJudgement, critical thinking and decision making Meets expectations	Sometimes exceeds expectationsJudgement, critical thinking and decision making Sometimes exceeds expectations	Consistently exceeds expectationsJudgement, critical thinking and decision making Consistently exceeds expectations	Not applicableJudgement, critical thinking and decision making Not applicable
Technical skills	Fails to meet expectationsTechnical skills Fails to meet expectations	WeaknessTechnical skills Weakness	Meets expectationsTechnical skills Meets expectations	Sometimes exceeds expectationsTechnical skills Sometimes exceeds expectations	Consistently exceeds expectationsTechnical skills Consistently exceeds expectations	Not applicableTechnical skills Not applicable

Communicator *

	Fails to meet expectations	Weakness	Meets expectations	Sometimes exceeds expectations	Consistently exceeds expectations	Not applicable
Effective interactions and rapport with patient / family	Fails to meet expectationsEffective interactions and rapport with patient / family Fails to meet expectations	WeaknessEffective interactions and rapport with patient / family Weakness	Meets expectationsEffective interactions and rapport with patient / family Meets expectations	Sometimes exceeds expectationsEffective interactions and rapport with patient / family Sometimes exceeds expectations	Consistently exceeds expectationsEffective interactions and rapport with patient / family Consistently exceeds expectations	Not applicableEffective interactions and rapport with patient / family Not applicable

Collaborator *

	Fails to meet expectations	Weakness	Meets expectations	Sometimes exceeds expectations	Consistently exceeds expectations	Not applicable
Effective team participation and leadership skills	Fails to meet expectationsEffective team participation and leadership skills Fails to meet expectations	WeaknessEffective team participation and leadership skills Weakness	Meets expectationsEffective team participation and leadership skills Meets expectations	Sometimes exceeds expectationsEffective team participation and leadership skills Sometimes exceeds expectations	Consistently exceeds expectationsEffective team participation and leadership skills Consistently exceeds expectations	Not applicableEffective team participation and leadership skills Not applicable

Manager *

	Fails to meet expectations	Weakness	Meets expectations	Sometimes exceeds expectations	Consistently exceeds expectations	Not applicable
Case management and efficiency	Fails to meet expectationsCase management and efficiency Fails to meet expectations	WeaknessCase management and efficiency Weakness	Meets expectationsCase management and efficiency Meets expectations	Sometimes exceeds expectationsCase management and efficiency Sometimes exceeds expectations	Consistently exceeds expectationsCase management and efficiency Consistently exceeds expectations	Not applicableCase management and efficiency Not applicable

Health Advocate *

	Fails to meet expectations	Weakness	Meets expectations	Sometimes exceeds expectations	Consistently exceeds expectations	Not applicable
Attention to preventative measures, vigilance, situational awareness	Fails to meet expectationsAttention to preventative measures, vigilance, situational awareness Fails to meet expectations	WeaknessAttention to preventative measures, vigilance, situational awareness Weakness	Meets expectationsAttention to preventative measures, vigilance, situational awareness Meets expectations	Sometimes exceeds expectationsAttention to preventative measures, vigilance, situational awareness Sometimes exceeds expectations	Consistently exceeds expectationsAttention to preventative measures, vigilance, situational awareness Consistently exceeds expectations	Not applicableAttention to preventative measures, vigilance, situational awareness Not applicable

Scholar *

	Fails to meet expectations	Weakness	Meets expectations	Sometimes exceeds expectations	Consistently exceeds expectations	Not applicable
Commitment to ongoing learning / best evidence practice	Fails to meet expectationsCommitment to ongoing learning / best evidence practice Fails to meet expectations	WeaknessCommitment to ongoing learning / best evidence practice Weakness	Meets expectationsCommitment to ongoing learning / best evidence practice Meets expectations	Sometimes exceeds expectationsCommitment to ongoing learning / best evidence practice Sometimes exceeds expectations	Consistently exceeds expectationsCommitment to ongoing learning / best evidence practice Consistently exceeds expectations	Not applicableCommitment to ongoing learning / best evidence practice Not applicable

Professional *

	Fails to meet expectations	Weakness	Meets expectations	Sometimes exceeds expectations	Consistently exceeds expectations	Not applicable
Sense of responsibility (punctual, prepared and reliable)	Fails to meet expectationsSense of responsibility (punctual, prepared and reliable) Fails to meet expectations	WeaknessSense of responsibility (punctual, prepared and reliable) Weakness	Meets expectationsSense of responsibility (punctual, prepared and reliable) Meets expectations	Sometimes exceeds expectationsSense of responsibility (punctual, prepared and reliable) Sometimes exceeds expectations	Consistently exceeds expectationsSense of responsibility (punctual, prepared and reliable) Consistently exceeds expectations	Not applicableSense of responsibility (punctual, prepared and reliable) Not applicable
Insight (open to feedback, knows own limitations	Fails to meet expectationsInsight (open to feedback, knows own limitations Fails to meet expectations	WeaknessInsight (open to feedback, knows own limitations Weakness	Meets expectationsInsight (open to feedback, knows own limitations Meets expectations	Sometimes exceeds expectationsInsight (open to feedback, knows own limitations Sometimes exceeds expectations	Consistently exceeds expectationsInsight (open to feedback, knows own limitations Consistently exceeds expectations	Not applicableInsight (open to feedback, knows own limitations Not applicable

Global Competency *

Fails to meet expectations	Weakness	Meets expectations	Sometimes exceeds expectations	Consistently exceeds expectations
Fails to meet expectationsSense of responsibility (punctual, prepared and reliable) Fails to meet expectations	WeaknessSense of responsibility (punctual, prepared and reliable) Weakness	Meets expectationsSense of responsibility (punctual, prepared and reliable) Meets expectations	Sometimes exceeds expectationsSense of responsibility (punctual, prepared and reliable) Sometimes exceeds expectations	Consistently exceeds expectationsSense of responsibility (punctual, prepared and reliable) Consistently exceeds expectations

Discussed with Learner *

Yes	No
YesYes Yes	NoYes No

Comments (strengths, weaknesses)

Topics Discussed