Teacher Assessment

Please fill out the following information regarding your learner experience. The information is only shared with the Chief and provided in a summary form to your teacher every 6-12 months.

Hospital Site *

Teacher

Date of Assessment *

Please rate your experience below

My teacher was ... *

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
approachable and enthusiastic	Strongly Disagreeapproachable and enthusiastic Strongly Disagree	Disagreeapproachable and enthusiastic Disagree	Neutralapproachable and enthusiastic Neutral	Agreeapproachable and enthusiastic Agree	Strongly Agreeapproachable and enthusiastic Strongly Agree
able to challenge and stimulate thinking	Strongly Disagreeable to challenge and stimulate thinking Strongly Disagree	Disagreeable to challenge and stimulate thinking Disagree	Neutralable to challenge and stimulate thinking Neutral	Agreeable to challenge and stimulate thinking Agree	Strongly Agreeable to challenge and stimulate thinking Strongly Agree
appropriately available for clinical supervision	Strongly Disagreeappropriately available for clinical supervision Strongly Disagree	Disagreeappropriately available for clinical supervision Disagree	Neutralappropriately available for clinical supervision Neutral	Agreeappropriately available for clinical supervision Agree	Strongly Agreeappropriately available for clinical supervision Strongly Agree
a role model (professional / communicator / collaborator)	Strongly Disagreea role model (professional / communicator / collaborator) Strongly Disagree	Disagreea role model (professional / communicator / collaborator) Disagree	Neutrala role model (professional / communicator / collaborator) Neutral	Agreea role model (professional / communicator / collaborator) Agree	Strongly Agreea role model (professional / communicator / collaborator) Strongly Agree
overall an effective teacher	Strongly Disagreeoverall an effective teacher Strongly Disagree	Disagreeoverall an effective teacher Disagree	Neutraloverall an effective teacher Neutral	Agreeoverall an effective teacher Agree	Strongly Agreeoverall an effective teacher Strongly Agree

Comments (strengths / weaknesses)

Prove you are human *