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Pat Capps Covey College of Allied Health Professions
Department of Cardiorespiratory Care
 
 
 
Affective Assessment Rating Form
   
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University of South Alabama
Pat Capps Covey College of Allied Health Professionals
Cardiorespiratory Care (CRC) Affective Assessment Guidelines
Department of Cardiorespiratory Care
Office: 445-9284

Use these guidelines to complete the CRC Affective Assessment (AA) rating form. When the score is a “1" or “2," please provide a comment on the AA rating form.

A. Attendance and punctuality
5 = Far exceeds expectations: Always on time, always present according to schedule - perfect attendance.
4 = Exceeds expectations: Tardy or absent no more than 1 occasion because of extenuating circumstances; called clinical site to notify. (Part of the CRC attendance policy.)
3 = Meets expectations: Tardy or absent no more than 2 occasions because of extenuating circumstances; called clinical site to notify. (Part of the CRC attendance policy.) Seeks to make up lost time.
2 = Falls below expectations: Tardy or late no more than 3 times (OR failed to give proper notification as described in policy for 1 or 2 occurrences of being tardy or absent).
1 = Falls far below expectations: Tardy or late more than 3 times; habitual problem. Rejects efforts to make up lost time.
X = Insufficient information to provide a valid rating; this scale is not applicable.

B. Professional attitude toward patients
5= Far exceeds expectations and always maintains professional attitude, communicates well with patients, is always sensitive and attentive to patient’s emotions, needs, rights, and comfort. No inappropriate behavior or words. Always patient, considerate, accommodating. Always mature. No lapses in any area.
4= Exceeds expectations and has rare lapse in professional attitude, communication, sensitivity, speech, or behavior. Rare lapse in patience, consideration, accommodation, rarely immature.
3= Meets expectations and maintains acceptable professional attitude, communication, sensitivity, speech, and behavior toward patients. Occasionally acts immaturely, or sometimes lacks patience, consideration, accommodating attitude.
2= Falls below expectations and sometimes lacks professional attitude, communication, sensitivity, speech, or behavior toward patients. Often behaves immaturely, or more often lacks patience, consideration, accommodating attitude.
1= Falls far below expectations and often has poor professional attitude, communication, sensitivity, speech, or behavior toward patients. Frequently displays immaturity or impatience. Frequently lacks consideration, accommodating attitude.
X = Insufficient information to provide a valid rating; this scale is not applicable.

C. Work ethic - task completion
5 = Far exceeds expectations: Excellent output. Always eager for more tasks. “Exceptionally hard worker.”
4 = Exceeds expectations: Very good output. Sometimes looks for more tasks. “Hard worker.” More than appropriate for student at this level of education.
3 = Meets expectations: Finishes most tasks in a timely manner. “Good worker.” Satisfactory output - appropriate for student at this level of education.
2 = Falls below expectations: Often unable to finish many tasks in a timely manner. Sometimes slow and inefficient. Less than satisfactory output for a student at this level of education.
1 = Falls far below expectations: Unable to finish most tasks in a timely manner. Habitually slow and inefficient. “Poor worker.” Unsatisfactory output for a student at this level of education.
X = Insufficient information to provide a valid rating; this scale is not applicable.

D. Initiative - effective time management
5 = Far exceeds expectations: Always “reports to duty” on time for all clinical tasks, and always ready with all required “tools” (pen, stethoscope, forms/ documents, equipment for the task, etc.). Always enthusiastic and well-organized. Wastes no time on any project or task. Always takes initiative to accomplish more, learn more.
4 = Exceeds expectations: Usually on time and ready for the job. Usually has the required “tools.” Enthusiastic, organized. Wastes little time on tasks. Often takes initiative.
3 = Meets expectations: Mostly on time and ready for the job. Sometimes disorganized. Some wasted time and backtracking for “tools.” Takes some initiative; Satisfactory and appropriate for student at this level of education.
2 = Falls below expectations: Often late and/or not ready for the job. Disorganized. Unnecessarily wastes time. Rarely takes initiative; Unsatisfactory for student at this level of education.
1 = Falls far below expectations: Always late. Reluctant to work; requires frequent prodding. Never takes initiative.
X = Insufficient information to provide a valid rating; this scale is not applicable.

E. Response to supervision and constructive criticism
5 = Far exceeds expectations: Always reacts positively to supervision, guidance, and constructive criticism. Takes every opportunity to make changes and to improve. Seeks input from preceptor to check progress toward improvement.
4 = Exceeds expectations: Usually reacts positively to supervision, guidance, and constructive criticism. Often makes changes and works to improve. Sometimes seeks input from preceptor to check progress toward improvement.

E. Response to supervision and constructive criticism (continued)
3 = Meets expectations: Generally reacts positively to supervision, guidance, and constructive criticism. Sometimes makes changes and seeks improvement. Accepts input from preceptor regarding progress toward improvement .
2 = Falls below expectations: Sometimes reacts negatively and/or takes offense to supervision, guidance, and constructive criticism. Rarely makes changes to improve. Avoids having preceptor reassess progress toward improvement.
1 = Falls far below expectations: Often reacts negatively and/or takes offense to supervision, guidance, and constructive criticism. Makes no effort to improve.
X = Insufficient information to provide a valid rating; this scale is not applicable.

F. Record keeping - documentation
5 = Far exceeds expectations: Documentation and record keeping for medical records and department are exceptional and flawless.
4 = Exceeds expectations: Minor corrections rarely needed. Description of activities and assessments is usually complete, concise, and accurate.
3 = Meets expectations: Documentation is satisfactory and appropriate for student at this level of education.
2 = Falls below expectations: Many corrections needed. Description of activities and assessments often incomplete, too many words or inappropriate descriptions. Inaccurate or missing information. Unsatisfactory for student at this level of education.
1 = Falls far below expectations: Fails to provide acceptable documentation of activities/assessment. Unsatisfactory for student at this level of education.
X = Insufficient information to provide a valid rating; this scale is not applicable.

G. Integration and transfer of theory
5 = Far exceeds expectations: Consistently, accurately links theory to practical/clinical application. Actions, comments, questions/answers reflect integration and transfer of theory in all situations.
4 = Exceeds expectations: Usually links theory to practical/clinical application. Actions, comments, questions/answers reflect integration and transfer of theory in most situations.
3 = Meets expectations: Sometimes links theory to practical/clinical application. Actions, comments, questions/answers reflect integration and transfer of theory in some situations.
2 = Falls below expectations: Rarely links theory to practical/clinical application. Actions, comments, questions/answers do not reflect integration and transfer of theory in most situations.

G. Integration and transfer of theory (continued)
1 = Falls far below expectations: Is unaware of links between the theoretical and practical and/or clinical applications or cannot apply theory to practice.
X = Insufficient information to provide a valid rating; this scale is not applicable.

H. Professional attitude toward other professionals
5 = Far exceeds expectations: Always appropriate in behavior and speech. Pleasant, honest, courteous, friendly, tactful, positive. Exemplary, exceptional, flawless professional attitude.
4 = Exceeds expectations: Usually appropriate in behavior and speech. Mostly pleasant, honest courteous, friendly, tactful, positive. Excellent professional attitude with few minor flaws.
3 = Meets expectations: Attitude is satisfactory and appropriate for student at this level of education.
2 = Falls below expectations: Inappropriate in behavior or speech. Difficult to be in a working relationship. Often unprofessional or negative.
1 = Falls far below expectations: Totally inappropriate behavior or speech. Unprofessional or negative at all times.
X = Insufficient information to provide a valid rating; this scale is not applicable.

I. Appearance
3 = Meets or exceeds expectations: Clean, neat, well groomed. Acceptable personal hygiene. Appropriate professional appearance.
2= Falls below expectations: Often untidy and/or inappropriately dressed. Often not clean, needs attention to grooming and/or personal hygiene. Inappropriate for clinical rotation.
1= Falls far below expectations: Habitually unclean, untidy and/or inappropriately dressed. Needs attention to grooming and/or personal hygiene. Unacceptable for clinical rotation.

Please place all responses on the Affective Assessment (AA) form below. For any score of 1 or 2, provide a comment. Click Submit to submit the form to the USA CRC Department.


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AFFECTIVE ASSESSMENT (AA) RATING FORM
University of South Alabama
Pat Capps Covey College of Allied Health Professionals
Department of Cardiorespiratory Care
Office: 251-445-9284



Student:        Date:  
 
Course:        Hospital and Rotation:  
 
Score the student based on the CRC Affective Assessment Guidelines. For any score of 1 or 2, provide a comment explaining the issue(s) and give specific examples.

5 = far exceeds expectations
4 = exceeds expectations
3 = meets expectations
2 = below expectations
1 = far below expectations
x = not applicable

Click Submit to send this form to USA CRC Department.

 
A. Attendance and punctuality:   A.
 
B. Professional attitude toward patients:   B.
 
C. Work ethic- task completion:   C.
 
D. Initiative- effective time management:   D.
 
E. Response to supervision and constructive criticism:   E.
 
F. Record keeping - documentation:   F.
 
G. Integration and transfer of theory:   G.
 
H. Professional attitude toward other professionals:   H.
 
I. Appearance (maximum possible score = 3):   I.
 
Total Score (A-I):    
 
 
Comments (Indicate letter(s) A- I for reference before each comment):
 
Preceptor name:  
 
Email address:  
 
 
               

After clicking on send, please wait until webpage changes.








 
University of South Alabama Pat Capps Covey College of Allied Health Professions Department of Cardiorespiratory Care