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Deborah J. Ingersoll, Ph.D. Educational Resources Coordinator Improvement Focused Feed Forward To be completed by Clerkship/Course Director. Please return to Educational Resources Coordinator

Improvement-Focused Feed Forward is a clinical course mechanism for helping students that have identified deficiencies in behavioral, attitudinal, communication, fund of knowledge or professionalism characteristics and would benefit from special assistance. See UNC SOM Educational Policies: 7.02.

Date ______Clinical Course ______Reporting Clinical Course Director ______Student ______Date Participated in Clinical Course (mo/yr)______

Previous Clinical Courses Completed: First/Second Year: □ICM 1 □ICM 2 Third Year: □ Family Medicine □ Fund Acute Care □ Medicine □Ob/Gyn □ Pediatrics □ Psychiatry □ Surgery Fourth Year: □Ambulatory Care Sel □Acting Internship Sel □ Critical Care Sel □ Neurosciences Sel □ Elective 1 □ Elective 2 □ Elective 3

Core Competencies/Areas of Concern: □ Medical Knowledge □ Patient Care □ Professionalism □ Fund of Knowledge □ Clinical Skills □ Behavioral □ Communication □ Attitudinal

Explanation/example of how this area of concern was manifested during clinical course: ______

Summary of conference, formative feedback, and intervention techniques used during this course:______

Recommendations for remediation to be implemented during next clinical course: ______

Office of Student Affairs, CB 9535, 1050 Bondurant Hall, Chapel Hill, NC 27599-7000 Phone (919) 843-6171 Fax (919) 966-0730 [email protected] □ Discussed with student CD Signature ______

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Student Permission

I, ______, (grant/decline) permission to share the above information with my next clinical course director for the purpose of designing an educational plan for remediating the noted area(s) of concern. I understand that this information is confidential and that if these areas of concern are determined to constitute a risk of compromising patient care or disrupting the health care team, the clinical faculty in consultation with the clinical course director and other senior faculty may override my decision. I understand that a copy of this form will remain on file (separate from my permanent record) and may be reviewed by the Associate Dean for Student Affairs and/or the Student Promotions Committee. ______Student Signature Date ______Educational Resources Coordinator Signature Date

Override information: ______

Follow-Up Information (ERC)

Has student received previous Improvement-Focused Feed Forward Requests? ______Contact Associate Dean for Student Affairs or SPC? ______

Next clinical course: ______Clinical course director: ______Date contacted:______Date(s) of follow-up: ______

Is problem remediated? ______

Evidence of successful remediation or persistence of problem: ______

Comments: ______

11/14/06

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