EmailMe Form - Medical Assistant Evaluation (GCC)

What is the Full Name of your Extern? *

First Last

(Please enter the first and last name of your extern, ex. John Smith)

How many Total Days did the Extern Attend? *

(Please enter the number of total days attended, ex. 30)

How many Days was your Extern Absent? *

(Please enter the number days absent, ex. 2)

How many Days was your Extern Tardy? *

(Please enter the number days tardy, ex. 1)

(PLEASE NOTE: A total of 160 hours is required.)

Clinical Procedures (100 Hours):

Patient History/Data *

Below Average

Average

Above Average

Excellent

Patient Preparation for Examination *

Below Average

Average

Above Average

Excellent

Assist with Examination *

Below Average

Average

Above Average

Excellent

Vital Signs *

Below Average

Average

Above Average

Excellent

Care of Examination Room *

Below Average

Average

Above Average

Excellent

Injections *

Below Average

Average

Above Average

Excellent

Venipuncture *

Below Average

Average

Above Average

Excellent

Electrocardiogram *

Below Average

Average

Above Average

Excellent

Urinalysis *

Below Average

Average

Above Average

Excellent

Sterilization *

Below Average

Average

Above Average

Excellent

Setting Up Sterile Fields *

Below Average

Average

Above Average

Excellent

Specimen Collection *

Below Average

Average

Above Average

Excellent

Patient Instructions *

Below Average

Average

Above Average

Excellent

Administrative Procedures (60 Hours):

Telephone Techniques *

Below Average

Average

Above Average

Excellent

Appointment Scheduling *

Below Average

Average

Above Average

Excellent

Charting *

Below Average

Average

Above Average

Excellent

Insurance *

Below Average

Average

Above Average

Excellent

Coding *

Below Average

Average

Above Average

Excellent

Billing *

Below Average

Average

Above Average

Excellent

Collections *

Below Average

Average

Above Average

Excellent

Processing Mail *

Below Average

Average

Above Average

Excellent

Filing *

Below Average

Average

Above Average

Excellent

Typing *

Below Average

Average

Above Average

Excellent

Computer Knowledge and Skills *

Below Average

Average

Above Average

Excellent

General Comments:

(If you have any other comments please leave them in this box)

Overall Ability Grade: *

F .

C .

B .

A .

(Please choose a letter grade)

Overall Performance Grade: *

F .

C .

B .

A .

(Please choose a letter grade)

Your Name: *

Prefix First Last Suffix

(Please enter your name, ex. James Brown)

Physician's Name: *

Prefix First Last Suffix

(Please enter the physician's name, ex. Dr. James Brown)

Company or Office Name: *

(Please enter the name of the company or office for which you work)

Company or Office Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Company or Office Telephone Number: *

### - ### - ####

(Please enter the company or office telephone number)

Type of Practice: *

(Please enter the type of practice, ex. Dialysis)

Today's Date: *

MM / DD / YYYY

(Please enter today's date)