Student Assessment of Rural Clinical Rotation

Today's Date

Name

First Last

Arrival Date*

Departure Date*

Home City*

Home State*

Home Zip Code*

Placement Location

Practice Discipline

How did you hear about this particular rotation?

Why did you decide on this location?

Curious about this particular community
Family/Friends live there
Preceptor has good reputation
Recreational opportunities
Meets academic requirements

Indicate the factors that have influenced or will influence your choice of location for clinical practice. (USE SHIFT/CONTROL KEY TO CHOOSE MORE THAN ONE OPTION.)

Please state which of the factors listed above is the most important.

I plan to practice in the following setting:

I plan to seek employment in (USE SHIFT/CONTROL KEY TO CHOOSE MORE THAN ONE OPTION.):

For Undergraduates: I intend to study or continue studying in a health profession after graduation

Benefits of Placement in Rural Clinical Rotations. Please check all that apply .*

Refinement of clinical skills
Development of an appreciation for rural life
Increased cultural competence
Feel appreciated by rural community
Feel "at home" here; good place to raise a family
Meets academic objectives
Meets personal educational objectives

Other:

Suggestions for rotation improvement (USE SHIFT/CONTROL KEY TO CHOOSE MORE THAN ONE OPTION.)

Longer placement period
Shorter placement period
Assignment of more than one preceptor per student
Less stringent supervision by preceptor
More guidance by preceptor

Please identify any suggestions you might have for incoming students related to clinical rotations or housing.*

Please provide any additional comments and/or provide a story about your stay:

Please assign a numerical rating to the overall benefit you derived from your placement.

4 (Extremely Beneficial)
3
2 (Moderately Beneficial)
1
0 (No Benefit)

The name of my preceptor:

I discussed the values of Interprofessional Practice & Education with my preceptor.

Yes
No
Unsure

I participated in Interprofessional Practice & Education with a discipline other than my own.

Yes
No
Unsure

If you selected "Yes" to the previous question, please specify the discipline(s) other than your own that you participated in.

Did you engage with other professionals who were also students?

Yes
No
Not Sure

If you selected "Yes" to the previous question, please specify all the disciplines of the student(s) you engaged with.

If you selected "Yes" to the question BEFORE the previous one, please specify the school name(s) of the student(s) that you engaged with.

Additional Comments, including your impression of rural living:*

Agree or disagree with this statement: As a result of this clinical rotation, I plan to seek employment in Southwest Colorado.

If you agreed to the previous statement, may we contact you after graduation?

Yes
No

Anticipated graduation date:

Please provide permanent contact information:

Did you participate in a Service Learning Project?

Yes
No

If you completed a service learning project, where did you participate and how would you rate your experience?

Please write a 1-2 paragraph summary about your Service Learning Project and include: Description of your project; Where you completed the project; What impact you made; How it went; Your thoughts about the project, including any suggestions you may have.

701 Camino Del Rio, Suite 320, Durango CO 81301. Call 970-426-4284.
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Student Assessment (rev. 12.2017)