Date Observed/Performed

Clerkship

Emergency Medicine

Family Medicine Clerkship

Internal Medicine Clerkship

Obstetrics & Gynecology Clerkship

Pediatric Clerkship

Psychiatry Clerkship

Surgery Clerkship

Supervisor

Setting

Clinic

Hospital

ER

Simulation

Specific Location (i.e. name of clinic/hospital)

(text box)

Level of Involvement

Observed

Assisted

Performed

Patient Age

1-23 months

2-5 years

6-18 years

19-44 years

45-64 years

65+

Patient Gender

M/F

Patient Race

American Indian

Asian

Black

Hispanic/Latino

Pacific Islander

White

Other

Procedure

1st

2nd

3rd

Notes

(text box)