MDHA/SDH Mentorship Program - Mentee (Student) Observation Mentor Feedback Form
Thank you for your willingness to participate in the MDHA/SDH Mentorship Program. This program would not exist or be a success without your help - thank you!
Please fill out the information in Section 1 and complete the Mentee (Student) Observation Mentor Feedback in Section 2 within 1 week of your student's observation.
Email address *
Section 1
Please complete:
Mentor Name: *
Your answer
Mentee (student) Name: *
Your answer
Date of mentee (student) observation: *
Your answer
Section 2
Please respond to all 16 statements. There is room at the end of the evaluation to provide additional feedback/comments.
Mentee (Student) Observation Mentor Feedback
Thinking about your mentee (student) and their observation to your practice setting, on a scale of 1-5, how much do you agree or disagree with the following statements:
1. Mentee showed up on time: *
Strongly Disagree
Strongly Agree
2. Mentee was dressed appropriately (clinic attire including lab coat & name tag): *
Strongly Disagree
Strongly Agree
3. Mentee was positive, attentive & interested in the observation: *
Strongly Disagree
Strongly Agree
4. Mentee engaged with you, the mentor: *
Strongly Disagree
Strongly Agree
5. If possible/applicable the mentee engaged with clients & showed empathy towards clients:
Strongly Disagree
Strongly Agree
6. Mentee engaged with other office team members (i.e. dentist, dental assistant, receptionist, etc): *
Strongly Disagree
Strongly Agree
7. Mentee was respectful to you, your patients and the other office team members: *
Strongly Disagree
Strongly Agree
8. Mentee asked meaningful questions: *
Strongly Disagree
Strongly Agree
9. Mentee demonstrated effective and appropriate verbal communication skills: *
Strongly Disagree
Strongly Agree
10. Mentee demonstrated effective and appropriate nonverbal communication skills (appropriate body language, listening skills, tone, etc): *
Strongly Disagree
Strongly Agree
11. Mentee took initiative and provided help & assistance to you the mentor throughout the observation: *
Strongly Disagree
Strongly Agree
12. Mentee took initiative and provided help & assistance to the office team members: *
Strongly Disagree
Strongly Agree
13. Mentee followed direction & demonstrated strong work ethic where applicable: *
Strongly Disagree
Strongly Agree
14. Mentee used their cellphone for business unrelated to the observation: *
Strongly Disagree
Strongly Agree
15. This observation was of benefit to your mentee: *
Strongly Disagree
Strongly Agree
16. This observation was of benefit to me, the mentor: *
Strongly Disagree
Strongly Agree
Additional comments/feedback:
Your answer
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