Student Assignments

Required Forms:

All students must complete the following forms and turn them at the exam session, which is held on the last Friday of the clerkshipAll forms are located in Section II on pages 16-30.  The log forms help us monitor the quality of the clerkship experience. To ensure the accuracy of the data and to avoid getting overwhelmed, we recommend you do the data entry on a daily basis.

  1. Complete the Pre & Post-Clerkship Assessment form following the directions (pages 16-17).
  2. Log the Core Topic Requirements for Patient Encounters (page 7) on New Innovations.  Print out a final report of your procedures from New Innovations and turn in with all other assignments at the debriefing/evaluation session.
  3. Spend a minimum of one- half-day during the month with one community resource person/agency and complete the Agency Summary Information form (page 18) for this experience.  The community agency should provide care to underserved/at risk populations.
  4. Complete the Faculty-Observed Back Examination form on the FMCard (instructions page 19).  Card must be signed by faculty who has observed and reviewed the experience with you (FMCard located on page 20).
  5. Complete the Clerkship Mid-Cycle Feedback form (page 21).  Your site director must complete this form on New Innovations.
  6. Complete the Pennsylvania AHEC Clinical Report Form (Exit) CR-2 (pages 23-26).
  7. Complete the FMCard (page 20), and obtain the appropriate signatures regarding the SOAP notes, PICO Presentation, and direct observation of a history.
  8. All assignments, forms, duty hour and case logger reports are due at the beginning of the exam session, which will be held on the last Friday of the clerkship beginning at 8:00 a.m.