Modality/Clinic Evaluation Form
ARKANSAS STATE UNIVERSITY
MEDICAL IMAGING AND RADIATION SCIENCES DEPARTMENT
MODALITY/CLINIC EVALUATION FORM:
*This form should be completed by the student’s Radiography Program Director or Clinical Coordinator
Student’s Name: _____________________________________________________ Modality: _________________________________________________
Please evaluate the student on his/her actual observed performance or behaviors.
1. APPEARANCE: The student displayed professional attire, i.e. hair is clean, uniform was wrinkle free, shoes are clean, dental hygiene is observed, etc.
a. professionally dressed and exceptionally groomed (3)
b. professionally dressed and appropriately groomed (2)
c. inappropriately groomed, needs improvement (1)
(scrubs wrinkled or out of dress code)
d. poor hygiene routine, needs counseling (0)
2. MOTIVATION: The desire of the student to increase his/her capability.
a. highly motivated (3)
b. motivated (2)
c. inconsistent (1)
d. purposeless (0)
3. ENGAGEMENT: The student appeared engaged and interested.
a. sought additional information (3)
b. asked occasional questions (2)
c. needed occasional prodding (1)
d. purposeless or not engaged (0)
4. CONCERN FOR OTHERS: Consideration for others’ feelings and the student’s ability to view the
parameters of existing circumstances.
a. sincerely and actively concerned (3)
b. generally concerned (2)
c. occasionally concerned (1)
d. indifferent (0)
5. EMOTIONAL STABILITY: The student’s ability to react under stress in a mature and dependable
manner.
a. exceptionally stable (3)
b. generally well balanced (2)
c. excitable or unresponsive under stress (1)
d. generally hyperemotional or apathetic (0)
6. ADAPTABILITY: The student’s ability to interact with and under others’ direction.
7. ATTENDANCE: The student arrived at assigned place on time.
a. arrived early and in the correct location (3)
b. arrived on time and in the correct location (2)
c. arrived late or was not in the correct location at the assigned start time (1)
d. missed the originally scheduled date and this was an alternate date (0)
8. CONDUCT: The student demonstrated professional conduct and appearance.
a. always (3)
b. most of the time (explain) (2)
c. occasionally (explain) (1)
d. needs counseling (explain) (0)
9. PATIENT RAPPORT: The student’s ability to relate with ill people in such a way as to promote
confidence and understanding.
a. promoted confidence and understanding (3)
b. related well with sick (2)
c. had difficulty in developing rapport with sick people (1)
d. tended to be unconcerned and upset patients (0)
10. COMMUNICATION: The student’s ability to communicate on a professional level with physicians,
other staff, patients, and patient’s families (and anyone else in the healthcare environment).
a. always (3)
b. most of the time (explain) (2)
c. occasionally (explain) (1)
d. needs counseling (explain) (0)
11. OVERALL IMPRESSION: The student’s ability to be a productive member in this modality.
a. ___ Excellent (3)
b. ___ Good (2)
c. ___ Fair (1)
d. ___ Poor (0)
12. MISCELLANEOUS INFORMATION AND COMMENTS: Please give any further information that you feel
might be helpful in evaluating this student:
________________________________________________________________________________________________________________
Signature/Position Date
____________________________________ __________________________________
Email: Phone #