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Evaluation forms

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.

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


A summary of those meetings will also be included for the fellows’ records.

Evaluation of Fellow Performance

Evaluation of Rotation

Evaluation of Teaching Activities

Peer Evaluation for Consult Rotation Sign Out

Patient Satisfaction Form

Fellow Self-Assessment Form

Journal Club Self-Assessment Form

Journal Club Evaluation

MPGMG Lectures Evaluation

Assessment Tool Cognitive Evaluation (mini CEX)

Assessment Tool Functional (mini CEX)

Assessment Tool Gait and Falls (mini CEX)

Allied Health Professional Evaluation

Assessment Tools- Mini CEXs (below are individual CEXs and how many you should have done)

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

  1. Cognition
  2. Functional
  3. Gait and Falls
  4. Mood

For Family Meetings CEX- anytime you have a family meeting while on either Palli, UCLA NH, GEM

  • Family Meeting

IDT CEX- Meetings are usually done during HBPC and GEM

  • IDT Meeting

Communication with PCPs CEX- done on the Harbor rotation

  • Communication with PCPs