STAFF CHAPLAIN/PRECEPTOR FEEDBACK FORM

FOR CPE INTERN MID-UNIT REVIEW

NAME OF INTERN

NAME OF CHAPLAIN/PRECEPTOR

During the CPE program, feedback is solicited from a wide variety of sources – peers, supervisor, nurses/team members, and chaplain preceptors. This form asks for some specific information from the chaplain preceptor who will assist the interns in gaining knowledge about how they present themselves and how others perceive them. Chaplains are seen as a valuable source of feedback given their clinical training and experience with high level interpersonal functioning. Please be candid, as honest feedback is needed in order for the intern to know how better to improve.

Please bring THREE (3) COPIES of this completed form to the mid-unit meeting with Jill, the intern, and yourself. Thank you for your assistance with the intern’s learning process.

  1. Please give the intern some feedback about your observations and experience of his/her communication style, interpersonal relationship skills, listening ability, etc. Please name both strengths and areas of improvement. Also, have you noticed any change from the beginning of the program to now?

2.What are the strengths and growing edges for the intern with regard to professional presentation and appearance (appropriateness of professional dress, speech, mannerisms, etc.)?

3. Please comment on the degree to which the intern has been assertive to take initiative toward you (e.g., seeking you out to ask for help, orientation, or feedback about specific patient care questions). What have you observed about the intern's ability to take initiative in other settings (orientation, meetings, communication with nurses, etc.)?

4.How would you describe the intern as a learner? Does he/she seem able to take the role of intern/learner, a role which implies a person is in process, doesn’t “know it all”? How receptive /open has the intern been toward feedback that you have offered?

5.Please share any feedback or concerns you have received about the interns' ministry from other members of the care team (nurses, PCA’s, chaplains, etc.).

Preceptor feedback form 01/11

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