Reporting Period / Due Date
1-Sept 1-Nov 30* / December 15
2-December 1-31** / Jan 15
3-January 1-May 31* / June 15
4-June1 – 30** / July 15
5-July 1 -August 31** / Oct 15

Center______Reporting Period______

Community Based Student Education Collection Form

(ROTATIONS, CLERKSHIPS, INTERNSHIPS, COMMUNITY EXPERIENCES)

Please complete one form for each trainee

Date of training: ______Name of training site: ______

Training site type: ______such as CHC, FQHC

Length of training: ______hours

Training description:______

Trainee Name______

Address: ______

Permanent Address: ______

Email address: ______

Name school or residency enrolled in: ______

Year in School: ______or Residency: PGY1___ PGY2___ PGY3___ PGY4___

Did you participate in interprofessional team training?Yes ___No___(more than one discipline participating in training together)

What other disciplines participated in the team training? ______

Reporting Period / Due Date
1-Sept 1-Nov 30* / December 15
2-December 1-31** / Jan 15
3-January 1-May 31* / June 15
4-June1 – 30** / July 15
5-July 1 -August 31** / Oct 15

Center______Reporting Period______

Gender: M___ F___

Age: ______

Disadvantaged background?

Yes___ No___

If Yes, Education ___ Economic____Rural ____ Veteran Status: Y___ N___

Ethnicity:

Latino/Hispanic __ Not Latino/Hispanic___

Race:

____American Indian/Alaska Native

____Asian Represented

____Asian Unrepresented

____Black/African American

____Caucasian/White

____Native Hawaiian/Pacific Islander

____Other ______

Reporting Period / Due Date
1-Sept 1-Nov 30* / December 15
2-December 1-31** / Jan 15
3-January 1-May 31* / June 15
4-June1 – 30** / July 15
5-July 1 -August 31** / Oct 15

Center______Reporting Period______

Discipline:

Reporting Period / Due Date
1-Sept 1-Nov 30* / December 15
2-December 1-31** / Jan 15
3-January 1-May 31* / June 15
4-June1 – 30** / July 15
5-July 1 -August 31** / Oct 15

Center______Reporting Period______

Allopathic MD____

Student or Resident? S__ R__

Osteopathic Doctor_____

Student or Resident? S__ R__

Chiropractic____

Comm. Health Worker ____

Dental Hygiene_____

Dentistry_____

First Responder ____

Health Administrator ___

Health Ed/Pt Navigator ____

Health Info Systems____

Home Health Aide____

Laboratory Sciences ___

Marriage/Family Therapy____

Medical Assistant____

Nurse____

Nurse Midwife____

Nurse Practitioner____

Nutrition____

Optometry____

Pharmacy_____

Physical Therapy_____

Physician Assistant____

Podiatry______

Psychiatry______

Psychology______

Public Health_____

Social Work______

Veterinary Med.____

Allied Health (i.e.Radiology, Lab Tech______

Reporting Period / Due Date
1-Sept 1-Nov 30* / December 15
2-December 1-31** / Jan 15
3-January 1-May 31* / June 15
4-June1 – 30** / July 15
5-July 1 -August 31** / Oct 15

Center______Reporting Period______

Community Based Student Education

Post Experience Questionnaire

Thank you for participating in AHEC activities. Please rate the following statements.

This experience met the learning objectives

Strongly AgreeAgreeSomewhat AgreeDisagreeStrongly DisagreeNA

123456

I plan to apply information I learned from this experience

Strongly AgreeAgreeSomewhat AgreeDisagreeStrongly DisagreeNA

123456

This experience reinforced my interest to work in a primary care setting.

Strongly Agree Agree Somewhat Agree Disagree Strongly DisagreeNA 1 2 3 4 5 6

The knowledge obtained is relevant to my future career.

Strongly Agree Agree Somewhat Agree Disagree Strongly DisagreeNA 1 2 3 4 5 6

This experience reinforced my interest to work with vulnerable populations and/or in an underserved community.

Strongly Agree Agree Somewhat Agree Disagree Strongly DisagreeNA 1 2 3 4 5 6

This experience reinforced my interest to work in a rural setting.

Strongly Agree Agree Somewhat Agree Disagree Strongly DisagreeNA 1 2 3 4 5 6

Comments about the program: ______