Clinical Experience Reporting Form
(Exit) CR - 2

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1.  AHEC Region:  NW    NC    SE    SW    SC    NE    EC

2.  Today's Date:  / /   (mm/dd/yyyy)

3. City/State of Hometown:   

4.  Name:    (first, middle, last)

5.  Has your last name changed since you started your clinical rotation:  Yes  No

  If yes, what was your former last name: 

6.  Has your permanent address changed since entering AHEC rotations?  Yes  No

7.  If yes, please provide your new permanent address:

 
Address:
City:
State:
Zip:
 
 

8.  Has the clinical rotation you just completed influenced your feelings about the probability that you might practice in one of the following areas upon graduation?  (Choose one per section)

  Not very probable Somewhat probable Highly probable Haven't thought about it
In Pennsylvania:
In a Rural Area:
In an Undeserved Area:

9.  Please evaluate the following elements of the rotation which you have just completed:

  Extremely satisfied Satisfied Dissatisfied Extremely dissatisfied No opinion Doesn't apply
How much I learned:
My preceptor / trainer:
My living arrangements:

10  Please indicate the start and end dates of this rotation:

  Start:  / /          End:   / /   (mm/dd/yyyy)

11.  Indicate the total number of days in this clinical experience / rotation: 

12.  Check if this experience was primary care rotation:

Family Medicine General Pediatrics Internal Medicine
Other 

13.  Check your program of study:  (choose only one)

Allopathic Medicine General Dentistry Occupational Therapy
Osteopathic Medicine Dental Public Health Physical Therapy
Nurse Anesthetist Dental Hygiene Respiratory Therapy
Nurse Practitioner Pharmacy Dietician
Nurse Midwife Psychology Chiropractic
Undergraduate Nurse Social Work Public Health
Physician Assistant Health Administration Pediatric Medicine
Other 

14.  What is the name of your preceptor and/or community-based physician's name?

  Preceptor Name: 
  Physician Name: 

15.  Name and location where your rotation took place:

 
Facility Name:
Address:
City:
State:
Zip:

16.  What type of rotation is it?  (Only one answer please)

First Year Third Year Internship
Second Year Fourth Year Residency
Other 

17.  Your Email Address:    (required for internet submission)

Comments:  Please offer any positive or negative comments that relate to your experience in the clinical rotation you have just completed.  This will help us maintain and/or improve our clinical experiences. 
Your identity will remain anonymous.  


 
 
 

Northwest Pennsylvania Area Health Education Center  2006