Summative Clinical Elective Assessment

Fields denoted by an asterisk (*) are required.

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Demographic Information
Name of Supervisor Name of Supervisor First Last
University
Department
Supervisor's Email
Student's Name Student's Name First Last
Student Number
Student Email
Rotation Start Date Rotation Start Date / MM / DD YYYY
Rotation End Date Rotation End Date / MM / DD YYYY
Was the student absent?

Was the student absent? Yes No
Number of Days Absent
Reason for Absence:

Reason for Absence: Academic Leave Non-Academic Leave Illness
Was mid-rotation feedback given to the student?

Was mid-rotation feedback given to the student? Yes No
Is the student’s behaviour consistent with the CMA Code of Ethics?

Is the student’s behaviour consistent with the CMA Code of Ethics? Yes No