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MCSO/OSU-CHS
Basic format
NAME OF RESIDENT
*
John Brand, DO
Lynn Jestis, DO
Eric Lee, DO
Gina Madole, DO
Ryan Shaffer, DO
Andrew Hamill, DO
Michael Roach, DO
Monica Woodall, DO
Michael Boger, DO
Robert Gispanski, DO
Thomas Jarvis, DO
Christie Shanafelt, DO
Rotation Dates
Month
*
Jan
Feb
March
April
May
June
July
August
Sept
Oct
Nov
Dec
Year
*
2010
2011
2012
2013
2014
2015
Name of evaluator
*
involved physician
Lichert Scale 1=poor 3=average 5=excellent
CORE COMPETENCY EVALUATION
Did the intern / resident demonstrate Osteopathic Skills during this rotation?
*
1
2
3
4
5
UE
Did the Intern/Resident demonstrate adequate medical knowledge during this rotation?
*
1
2
3
4
5
UE
Did the intern / resident demonstrate professionalism during this rotation?
*
1
2
3
4
5
UE
Did the Intern / Resident demonstrate adequate interpersonal and communication skills during this rotation?
*
1
2
3
4
5
UE
Did the Intern / Resident demonstrate adequate patient care skills for their level of training?
*
1
2
3
4
5
EU
Did the Intern demonstrate adequate use of resource materials during this rotation?
*
1
2
3
4
5
UE
Did the Intern / Resident demonstrate punctuality?
*
1
2
3
4
5
UE
ROTATION SPECIFIC QUESTIONS
*
1
2
3
4
5
UE
Ability to
1
2
3
4
5
UE
Ability to perform
1
2
3
4
5
UE
Placement of
1
2
3
4
5
UE
Placement of
1
2
3
4
5
UE
Knowledge of
1
2
3
4
5
UE
Understands
1
2
3
4
5
UE
Basic use
1
2
3
4
5
UE
ROTATION SPECIFIC COMMENTS
Comments
*
🛈
Signature of Evaluator
*
UPIN
SSN
MCSO ID
MCSO ID
Date:
*
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