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Multi Sourse Feedback Form

This document contains a multi-source feedback assessment for a trainee's pediatric training. It rates the trainee across various skills and abilities using a grading scale. It includes space for comments from the trainer and trainee.

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dileepa Rathnayaka
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23 views

Multi Sourse Feedback Form

This document contains a multi-source feedback assessment for a trainee's pediatric training. It rates the trainee across various skills and abilities using a grading scale. It includes space for comments from the trainer and trainee.

Uploaded by

dileepa Rathnayaka
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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POST GRADUATE INSTITUTE OF MEDICINE

UNIVERSITYOF COLOMBO, SRI LANKA

IN SERVICE TRAINING ASSESSMENT

MD Paediatrics

MULTI SOURCE FEEDBACK (MSF)

Trainee’s name:

Date of assessment (dd/mm/yyyy):

Training Center:
1 2 3 4
Year of training:

Length of working relationship (in months):

You will be expected to provide a feedback on the work performance of the trainee with anonymous
feedback of at least 2 members of the hospital staff (seniors, peers, juniors, nurses and other health
professionals)

Below Above Well Unable


Meets
Unsafe Expectati Borderline Expectatio above to
expectations
Grading ons ns expectations comment
F E D C B A
Ability to diagnose
patient problems
Ability to formulate
appropriate
management plans
Ability to manage
complex patients
Awareness of his
own limitations
Responds to
psychosocial aspects
of patients
Appropriate
utilization of
resources e.g.
ordering
investigations
Ability to co-
ordinate patient care
Technical skills
(appropriate to
current practice)

54
Ability to apply up-
to-date / evidence
based medicine
Ability to manage
time effectively /
prioritize
Ability to deal with
stress
Commitment to
learning Willingness
and effectiveness
when
teaching/training
colleagues
Communication
with carers and/or
family
Ability to recognize
and value the
contribution of
others
Accessibility /
reliability
Leadership skills
Punctuality

**Overall Unsafe Below Borderline Meets Above Well above


performance Expectation Expectation Expectation Expectation

** Mandatory for the trainer to complete

Trainer‟s comments: Suggestion for development

Agreed action

Assessor‟s position: Consultant Senior Registrar

Assessor‟s signature:--------------------------------------- Assessor‟s Name:-------------------------------

Trainee‟s comments:

Trainee‟s signature: ------------------------------------------------

55

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