ATC – Trainee Evaluation Form To be completed by the faculty of the training program Name of Program Fellow's Name First Last PG Level: Name of Evaluator First Last Date of Evaluation MM slash DD slash YYYY Evaluator RoleProgram Director / Co-DirectorProgram CoordinatorOtherRole: Please Specify Evaluator Email Enter your email to receive a copy of your responses. Fellow EvaluationFor each of the following categories, please indicate: Not observed/ Not applicable, Outstanding, Satisfactory, Needs Improvement OR Unsatisfactory Fund of knowledge for head and neck surgical oncologyNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryFund of knowledge for microvascular reconstructive surgeryNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryThoroughness of patient managementNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryClinical problem solving/clinical judgmentNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryEmergency and critical care patient managementNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactorySurgical skills: MicroNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactorySurgical skills: AblativeNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryProfessional behavior with colleagues and peersNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryRapport with patients, empathyNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryAbility to effectively communicate clinical information to patientsNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryRapport with other health professionalsNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryClinical research performanceNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryEfficiency and work habitsNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryOwnership of patient careNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryTeaching and instructing abilityNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryAdministrative skillsNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryEndocrine decision makingNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryProficiency in ambulatory proceduresNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryNeck ultrasoundNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryUltrasound guided FNANot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryOverall clinical performanceNot observed/Not applicableOutstandingSatisfactoryNeeds ImprovementUnsatisfactoryAdditional Fellowship ActivitiesFor each of the following categories, please indicate: Adequate OR Insufficient. Write in answers where prompted. Time spent in clinicAdequateInsufficientCommentsAverage number of days spend in clinic weeklySatisfactory Completion of Key Indicator Case GoalsYesNoSpecific Case Type ConcernsAHNS Virtual Tumor Board Attendance: Met 60% attendance benchmark?YesNoUsage of AHNS Curriculum: At least 60% completed?YesNoCompletion of questions distributed through Dosed Daily: Met 70% participation benchmark?YesNoAHNS Journal Club participationAdequateInsufficientFormal Multidisciplinary Exposure:Radiation oncologyAdequateInsufficientMedical oncologyAdequateInsufficientComments/Details on participationMultidisciplinary Tumor Board InvolvementFor each of the following categories, please indicate: Yes OR No Fellow presents cases at tumor boardYesNoFellow organizes tumor boardYesNoEvaluation Type Interim: 6 Month Evaluation End of the Year: Summation Evaluation Other If 'other' please describe(Required) Evaluation Comments Δ Share:FacebookTwitterLinkedIn