#5 Preceptor Evaluation Form

Preceptor Evaluation

Instructions:

1. This evaluation is to be completed by the orientee following the completion of the orientation program.

2. The preceptor will provide the evaluation to each orientee and encourage them to complete it.

3. The orientee is to complete the evaluation honestly so it can be used as a tool to monitor the preceptor's success as a trainer, educator, coach, and mentor.

Facility Name *

Orientee's Name: *

Preceptor's Name *

In-House Coach Email Address

How would you rate the friendliness of the preceptor on your first day? *

Excellent

Good

Satisfactory

Poor

What, if anything, would have made you feel more welcome? *

How would you rate the preceptor's knowledge? *

Execellent

Good

Satisfactory

Poor

How were you treated by other CNAs and staff during your orientation? *

Execellent

Good

Satisfactory

Poor

Did you feel comfortable asking questions? *

Yes
No
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Did your preceptor answer your questions? *

Yes
No
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Did your preceptor ask questions to ensure you had understood the information and training? *

Yes
No
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Did your preceptor excite you about becoming a CNA and working in a long term care facility? *

Yes
No
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Explain: *

Did the preceptor act professionally during orientation with regard to:

Language: *

Yes

Appearance *

Yes

Treatment of Residents: *

Yes

Positive Attitude *

Yes

Respectful of Supervisors *

Yes

Overall evaluation of orientation: *

*Information gathered during this form submission are confidential and will not be shared or distributed outside the facility or company. The sole purpose of the journal is to gather information and tailor an action plan for mutual work and to achieve the goals and objectives of the partnership. No other use is intended.