North East Pennsylvania Area Health Education Center

Enhancing access to health care through education

Clinical Experience Reporting Form (Exit) CR - 2

The Pennsylvania AHEC, in partnership with your school, is seeking to help meet the primary care needs of our communities and to make health careers training a more valuable experience.  Results from this survey will be used to support these goals.  All survey responses are confidential.  Data will only be used within the AHEC program and never for commercial purposes.

 Please answer each item as completely as possible.

Date Completed? (Month/Day/Year)

Your name? (Last, First, Middle, Maiden)

Academic/Training Year

Training Category

Enrollment Status

Age Group

What is your discipline/specialty


What is the name of the facility where your rotation took place?

Name of the facility: Zipcode:

What is the name(s) of your preceptor(s) responsible for this rotation?

Preceptor Name (first last)

Preceptor Name (first last)

Was the clinical experience (rotation) you just completed labeled as (or could best be considered) which of the following?


What were the start and end dates of this clinical experience (rotation)?

Start date (Month/Day/Year): End date (Month/Day/Year):  

How much clinical time did you spend in this training/clinical experience? (If less than 1 day enter “1”.)

Did you complete this program (rotation)?

Do you intend to practice in Pennsylvania?
Do you intend to practice in a Primary Care Setting?
Do you intend to practice in a Medically Underserved Area?
Do you intend to practice in a Rural Area?

Please rate the clinical experience (rotation) you just completed with respect to the following:

Achievement of the learning objectives intended or stated for this experience
Achievement of my personal learning objectives
Accessibility of on-site learning resources (Internet, tutorials, etc.)
Accessibility of preceptor
Opportunity to deliver hands-on patient care
Accessibility of internet and other learning resources from my housing
Quality/condition/safety of housing
Quality of community lifestyle (i.e. resources/ culture/educational/social/entertainment)

What is your current address?(street address, city, state, zip, country)

What is your preferred email address?(Required for online submission)



Enter the below form code (all numbers)


Eastcentral - Northeast Pennsylvania Area Health Education Center
5662 Interchange Road Lehighton, PA 18235 | Phone: 610.379.2001 | Fax: 610.379.2005 |