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WVNCC Surgical Technology Program Preceptor Evaluation Form



  • Student: *

  • Preceptor: *

  • Facility: *

  • Surgery(s): *

  •  

    Please note that it is our goal to ensure students are performing and behaving with high standards.  We ask that our preceptors be open and honest as to performance, as well as attitude, with constructive criticism in order for our student to understand the areas they need improvement and also where they excel.  Please remember to evaluate the student for their performance as a student not employee.    Please feel free to contact us with any concerns.

    Tami Roscoe
    troscoe@wvncc.edu

    Sara Walter
    swalter5@wvncc.edu

    Erin Carr
    ecarr@wvncc.edu

     

     


  • Did the student introduce themselves and observe proper break times: *




  • Was the student properly attired with PPE (eyewear, double glove, lead) for all cases: *




  • Does the student work well as a team member: *




  • Does the student show initiative: *




  • Does the student correctly open sterile supplies: *




  • Does the student properly don their/his/her gown and gloves: *




  • Does the student properly gown and glove others: *




  • Does the student assist with set-up, or complete on their/his/her own: *




  • Does the student properly perform initial counts: *




  • Does the student properly identify, assemble, utilize, and care for surgical instruments, supplies, and equipment: *




  • Does the student assist with draping and the securing of cords, or complete on their own: *




  • Does the student properly load and/or pass instrumentation, blades, sutures, and medications: *




  • Does the student maintain sterility and safety, as well as move appropriately within the sterile field: *




  • Does the student properly perform closing counts: *




  • Does the student assist with the safe transfer of patients: *




  • Does the student assist with room turnover: *




  • Did the student understand the procedures being performed, or ask questions if unsure: *




  • Does the student demonstrate responsible, accountable, and professional behavior consistent with the role and standards of practice of the surgical technologist: *




  • Does the student use professional, respectful, and appropriate verbal and nonverbal communication with all members of the healthcare team: *




  • Did the student provide you with a completed Preceptor Evaluation Form, filled out in its entirety: *




  • Did the student provide you with a completed Case Log, with the appropriate scrub roles, filled out in its entirety: *




  • Overall Performance : *



  • Please list below any comments, overall feedback, strengths, and/or recommendations for improvement below:

  • Preceptor: by entering your full name below, you confirm that the above information is complete and accurate: *

  •  

    This section is to be completed by faculty upon entering grades into Brightspace

     

    In Gradebook as Preceptor Evaluation: _______   Course:    Clinical Experience      CP III      CPIV   

    Year: __________________________________    Semester:    Summer    Fall    Spring          



* = Required

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