Evaluation forms

Reporting Milestones

Below is a list of evaluations that are filled out either by fellows or by faculty members, learners, patients, peers or allied health professionals during the fellowship year.  The fellow shall be notified within a reasonable time if an evaluation indicates unsatisfactory performance.

A one-on-one meeting between each fellow and the fellowship director will occur mid and end of year to review all fellows’ evaluations and identify strengths, weakness, goals and methods for improvement. A summary of those meetings will also be included for the fellows' records.

We have designed a checklist of required evaluations that are for you to collect throughout the year. The evaluations listed on this checklist are for you to keep track of.

Evaluation Checklist


Evaluation of Fellow Performance

Evaluation of Rotation

Evaluation of Teaching Activities

Evaluation in and of Continuity Clinics

Allied Health Professional Evaluation

Peer Evaluation Rotation Sign Out

Patient Satisfaction Form

Fellow Self-Assessment Form

Journal Club Self-Assessment Form

Lectures Evaluations (e.g. Thursday lecture, journal clubs, PM&R, community lecture)

Assessement Tools- Mini CEXs

Below are individual CEXs and how many you should have done by the end of the fellowship year

Of the four listed below you should have 3x per year around October, February, May

  • Cognition
  • Functional
  • Gait and Falls
  • Mood

For Family Meeting CEX- Anytime you have a family meeting while either on Palliative Care, UCLA NH, or on WLA GEM (but you can ask your attending to evaluate you whenever you have a family meeting on ANY rotation. Doesn't have to be the clinics listed above)

  • Family Meeting

IDT CEX- Meetings are usually done during HBPC and GEM

  • IDT Meeting

Transitions in Care CEX- done while on the Harbor rotation (but you can ask to be evaluated any time an attending observes or hears you sign out a patient or a service)

  • Transitions in Care