Medical Intern Evaluation Form

From : - 2025/07/08 م , To : - 2028/07/14 م

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Medical Intern Evaluation Form

* Intern Name

* Rotation Name

* Hospital

* Date of Rotation

* Type of Rotation

A. Medical knowledge and Skills

* 1. History – taking and physical skills

* 2. Understand mechanisms of diseases and outlines of diagnosis and management

3. Quality of writing medical-records and case presentation

B. Practice-based learning and improvement

* 4. Ability of self-evaluation and accepting feedback

* 5. Effort to improve knowledge and skills

C. Interpersonal and communication skills

* 6. Keeping professional relations with senior staff, colleagues and other medical-staff

* 7. Relations with patient and patient-family

D. Professionalism

* 8. Attendance and punctuality

* 9. Respect and honesty

* 10. Accountability and responsibility

Summary

* Total Score

* Overall Grade

Notes Section

Notes: In order to pass the rotation, the intern should have a total score of 60% (pass). In case of failure of intern, reasons, justifications, and feedback must be discussed with the intern prior to submission of this form.

* Evaluating-Consultant comments

* Was this assessment based on discussion with another consultant?

* Other staff ?

Signatures Section

* Evaluating-Consultant Name

Evaluating-Consultant Signature

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* Head of Department (Hospital)

* Signature – Head of Department

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* Rotation Coordinator Name

Signature – Rotation Coordinator

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* Intern Signature

Institution Seal

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Umm Al-Qura University

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College of Medicine in Al-Qunfudah

Medical Intern Evaluation Form

Medical Intern Evaluation Form

A. Medical knowledge and Skills

B. Practice-based learning and improvement

C. Interpersonal and communication skills

D. Professionalism

Summary

Notes Section

Signatures Section

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Official government website of the Government of Kingdom of Saudi Arabia KSA How to verify

Link to official Saudi websites end with edu.sa

Government websites use the HTTPS protocol for encryption and security.

Umm Al-Qura University

Medical Intern Evaluation Form

Medical Intern Evaluation Form

A. Medical knowledge and Skills

B. Practice-based learning and improvement

C. Interpersonal and communication skills

D. Professionalism

Summary

Notes Section

Signatures Section

Official government website of the Government of Kingdom of Saudi Arabia KSA
How to verify