Elective:
Dates:
Course Number:
Student Name:
Location:

For each of the following statements, click the response that most accurately indicates the extent to which you are in agreement with the statement using the following scale:
1=Strongly Disagree, 2=Disagree, 3=Agree, 4=Strongly Agree, N/A= Not Applicable.

The elective had clear goals and objectives.
1 2 3 4 N/A

The elective content matched the goals and objectives.
1 2 3 4N/A

The elective was well organized.
1 2 3 4N/A

Evaluation(s) were related to elective content, goals, and objectives.
1 2 3 4N/A

Evaluation(s) were fair.
1 2 3 4N/A

Faculty were available and willing to help.
1 2 3 4 N/A

Faculty were appropriately responsive to student concerns.
1 2 3 4 N/A

I gained knowledge from the elective.
1 2 3 4 N/A

This elective integrated basic and clinical science.
1 2 3 4 N/A

This elective helped me to be more responsible for my own learning.
1 2 3 4 N/A

The elective helped me understand a physician’s role in promoting and maintaining health.
1 2 3 4 N/A

The elective was appropriately helpful in developing my clinical knowledge and skills.
1 2 3 4N/A

The elective increased my understanding of professionalism in medicine.
1 2 3 4 N/A

The elective helped me to develop skill in using medical information resources.
1 2 3 4 N/A

I was given increased responsibility beyond my Year III clerkships.
1 2 3 4 N/A

For the following statements, answer using the following scale:
1 = Poor, 2 = Fair, 3 = Good, 4 = Outstanding

Rate the overall quality of this elective.
1 2 3 4 N/A

Add any comments that you may have about the strengths of this elective. Please be professional in all your comments.

Add any comments that you may have about the weaknesses of this elective. Please be professional in all your comments.