HTML Preview Dental Assisting Practicum Evaluation Form page number 1.
NORTHERN ESSEX COMMUNITY COLLEGE
DENTAL ASSISTING PROGRAM
45 FRANKLIN STREET
LAWRENCE, MA 01841
KERIN HAMIDIANI / DOROTHY VANNAH
(978) 738-7427 (978) 738-7216
Fax (978) 738-7146
khamidiani@necc.mass,edu dvannah@necc.mass.edu
PRACTICUM EVALUATION FORM
Student Name _______________________________________________ Externship Office _____________________________
Your evaluation of this student’s practicum experience helps identify areas in which the student is strong as well as those where
improvement is needed. The Dental Assisting Program also benefits by having information concerning areas that may need more
attention and focus. Please complete one form for each of your students at the end of their rotation, and mail or fax these forms to the
NECC Dental Assisting Program. Please do not give these evaluations to the students.
Instructions: Using the following scale, please rate the student in the areas listed by circling the appropriate box.
4
EXCELLENT
Performs at an
exceptionally high level
3
GOOD
Performs somewhat above an
average or satisfactory level
2
FAIR
Performs mostly at an
average or satisfactory level
1
POOR
Performs below
average; work not satisfactory
NA
Student had no
opportunity to
perform this task
4
Excellent
3
Good
2
Fair
1
Poor
NA
1. PROFESSIONAL APPEARANCE
A. Complies with NECC dress code (e.g. clean uniform, no tobacco
odor, good personal hygiene, groomed hair and nails).
4
3
2
1
II. PROFESSIONAL CONDUCT
A. Consistently arrives on time.
4
3
2
1
B. Maintains good attendance.
4
3
2
1
C. Demonstrates honesty (SCORE AS “4” OR “1” ONLY)
4
1
D. Seeks out appropriate help when unsure of procedure.
4
3
2
1
E. Maintains confidentiality of patients and staff and avoids gossip
and inappropriate comments.
4
3
2
1
F. Communicates and relates well to dental patients.
4
3
2
1
G. Exhibits work efficiency and willingness to work.
4
3
2
1
H. Is open and responsive to constructive criticism.
4
3
2
1
I. Exhibits a spirit of team-work and cooperation.
4
3
2
1
Comments on this student’s Professional Appearance and/or Conduct:
III. DENTAL ASSISTING SKILLS
A. Patient/Assistant Preparation
1. Greets and positions patient.
4
3
2
1
2. Assistant positioning, light positioning (Ergonomics).
4
3
2
1
3. Gives pre and post-operative instructions.
4
3
2
1
B. Proficiency in preparing tray set-ups (List types prepared).
______________________________________________________
______________________________________________________
4
3
2
1
C. Maintaining field of operation:
1. Evacuating oral cavity.
4
3
2
1
2. Applying air and water.
4
3
2
1
3. Retracting cheeks, lips, tongue.
4
3
2
1