Supplemental Resident Evaluation

Carle Supplemental Surgery Resident Evaluation

You are being asked to complete this supplemental evaluation of Dr. David Chiang, a Carle Surgical Resident with whom you worked in January 2016.

We are collecting this information as part of a remediation plan, and the information you provide will be reviewed by his program director before being shared with him.

Please provide as much detail as possible in your responses, as we will use this information to help assess the resident's progress, as well as to supply specific direction for improvement. Thank you!

* Your name:

* In what context did you work with this resident (select all that apply)?

Daily patient care

On-call

* 1. What is the resident doing well?

* Examples of what the resident is doing well (be as specific as possible):

* 2. What concerns do you have about this resident’s performance?

* Examples of what leads you to be concerned (be as specific as possible):

* 3. This resident's performance was _________________ what I expect from a trainee at the same level (select the response that best completes the blank according to your experience this past month).

behind

on track with

ahead of

* Explain your response (be as specific as possible):