Student Name:____________________________ Student #:_________________

Covered Period: DD / MM /20____ to DD / MM / 20____

Week: ______________

Clinical Rotation:__________________________ Location: _____________________


Day

Case short description
Clinical Supervisor or
Designees Name,
Signature & Comment
Day 1
S M T W T

Date: DD / MM
/20__





Day 2
S M T W T
Date: DD / MM
/20__





Day 3
S M T W T

Date: DD / MM
/20__





Day 4
S M T W T

Date: DD / MM
/20__





Day 5
S M T W T

Date: DD / MM
/20__






Clinical Supervisors
Name, signature &
comment:
DD / MM /20___

Students comment:
DD / MM /20___

Formative Feedback Given Not Given Clinical Supervisors Name & Signature
* This form is for official use only; revised as of March 2010

Instruction to the tutor: Please send immediately after the session
to Student Affairs office (Mail code 3155)


King Saud bin Abdulaziz
University
for Health Sciences
College of Medicine
Female Medical Student Branch
Form UCE 10:
Clinical Attachment Performance
Feedback
(to be used in clinical rotations with daily activities)

0 Not achieved
1 Poor
2 Below average
3 Borderline
4 Satisfactory