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Preceptor Evaluation Form

For Preceptors: Please fill out the form below after your student has completed their "Day With A Doctor"

First name (Student)*

Last name (Student)*

Name of Physician*

Email (Physician)*

Date Spent With Student*

Month

Day

Year

In order to assist the Evaluation Committee in the selection of the scholarship candidates, you are asked to rate the student named above in the following categories:

Please use numerals 1 through 10, with 10 being the highest possible rating.

General Appearance*

Personality*

Attitude*

Interest*

Emotional Stability*

Relationship to Others*

Understanding*

Please Comment: Why do you think this student should (or should not) win a DOT Scholarship/Award?*

Physician's Signature*

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PO Box 2274 Huntington, New York 11743

631.851.1400

info@scms-sam.org

© 2026 Suffolk County Medical Society

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