HOLY NAME UNIVERSITY

Department of Medical Technology

Janssen Heights, Dampas District, Tagbilaran City, Bohol

MEDICAL TECHNOLOGY INTERNSHIP

EVALUATION TOOL FOR PRACTICAL EXAM
_____SEMESTER; S.Y.__________

NAME OF INTERN :_______________________________ RATING :_____________%

SECTION ASSIGNMENT:_______________________________ INSTITUTION:_____________
DATE OF ROTATION :_______________________________

Rating Scale:
4.0 = EXEMPLARY: The performance of the learner is beyond the requirements. (>86%)
3.0 = SATISFACTORY: The performance of the learner is within the requirements. (75-85%)
2.0 = DEVELOPING: The performance of the learner shows some deficiencies. (64-74%)
1.0 = BEGINNING: The performance of the learner shows many deficiencies. (<64%)
A. KNOWLEDGE (30%) 4.0 3.0 2.0 1.0
At the end of the exam, the interns will:
1. explain the principle of the tests done
2. associate the factors or considerations which can affect the tests
3. discuss the clinical significance of the tests
B. SKILLS (50%)
At the end of the exam, the interns will:
1. perform the required test with confidence
2. demonstrates speed and efficiency
3. shows accuracy and precision
4. exhibits cleanliness and orderliness of work
5. do after care and or patient care
C. ATTITUDE (20%)
At the end of the exam, the interns will:
1. perform aseptic techniques in the performance of the procedure
2. demonstrate punctuality, courtesy and respect
3. exhibit honesty and integrity
4. show enthusiasm and initiative

KNOWLEDGE = Average Rating ________ x 0.30 = ____________

SKILLS = Average Rating ________ x 0.50 = ____________
ATTITUDE = Average Rating ________ x 0.20 = ____________

Total Numerical Grade ______/4 x 100 _____________%

_________________________________ ___________________________________
PRINTED NAME AND SIGNATURE OF INTERN PRINTED NAME AND SIGNATURE OF INSTRUCTOR

DATE: ________________________________ DATE: __________________________________