Person Making Visit:

Rotation:

Date and Time of Appointment:   

Location:

Preceptor or Designee:

Type of Visit: Periodic Follow-Up Other

Main Discussion Points During Meeting:

Faculty Development Opportunities:

Left materials (If yes, please list):

Reviewed procedures (If yes, please list):

Reviewed student feedback

Reviewed areas of concern/praise

Suggestions for Improvement:

Additional comments: