Multisource Feedback for Clinical Supervisors: STUDENT FORM

Maastricht Clinical Teaching Questionnaire1


This is a TWO sided form. All responses will be collated and returned to the clinical supervisor.


Clinical Supervisor’s Surname: ____________________

First name: _____________________

Date: _________________

Health profession you are studying (e.g. nursing, physiotherapy, medicine etc): _______________

Your year of study: ________________

Length of time you have worked with this clinical educator: ____________ (indicate days or weeks or months)

Please indicate your level of agreement with the

following statements:

Fully                                                                                           Fully

  Disagree                                                                                    Agree

Unable to comment 








This clinical supervisor:







1.     consistently demonstrated how different tasks

should be performed







2.    clearly explained the important elements for the execution of a given task







3.    created sufficient opportunities for me to

observe them.







4.    was a role model as to the kind of health

professional I wish to become







This clinical supervisor:







5.    observed me multiple times during patient








6.    provided me with useful feedback during or following direct observation of patient encounters







7.     helped me understand which aspects I needed to improve







This clinical supervisor:







8.     Adjusted teaching activities to my level of experience







9.     Offered me sufficient opportunities to perform activities independently







10.  Supported me in activities I find difficult to perform







11.  Gradually reduced the support given to allow me to perform certain activities more independently







Please indicate your level of agreement with the following statements:

    Fully                                                                                                  Fully

    Disagree                                                                                         Agree          

Unable to comment 








This clinical supervisor:







12.    Asked me to provide a rationale for my actions







13.    Helped me to become aware of gaps in my knowledge and skills







14.    Asked me questions aimed at increasing my understanding







15.    Encouraged me to ask questions to increase my understanding







This clinical supervisor:







16.    Stimulated me to explore my strengths and weaknesses







17.    Stimulated me to consider how I might improve my strengths and weaknesses







This clinical supervisor:







18.    Encouraged me to formulate learning goals.







19.    Encouraged me to pursue my learning goals.







20.    Encouraged me to learn new things.







This clinical supervisor:







21.  Created a safe learning environment.







22.  Took sufficient time to supervise me.







23.  Was genuinely interested in me as a student.







24.  Showed me respect.







Overall, give this clinical supervisor an overall assessment (1 – 10) of their clinical teaching performance (10 =excellent):   



What are the strengths of this clinical supervisor?





Which aspects of the performance of this clinical supervisor can be improved?




1Stalmeijer R, Dolmans D, Wolfhagen I, et al. 2010. Combined student ratings and self-assessment provide useful feedback for clinical teachers. Advances in Health Sciences Education 15(3) 315-28.

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