Referral to Student Development Team

Referral to Student Development Team

Student First Name*

Student Last Name*

Name of person referring*

Email address of person referring*

Course Name*

Select all that apply

SCoPE

Essentials 1.1

Essentials 1.2

Essentials 1.3

Doctoring 1.1

Doctoring 1.2

Doctoring 1.3

Intersessions

Other (please explain)

Please explain*

Setting*

Select all that apply

PBL

Lab groups

Student-led clinics

Learning Community

House

Large group session

Small group session

Issue identified during assessment (quiz, other test, OSCE)

Other (please explain)

Please explain*

Type of Concern*

Select all that apply

Low performance or missing 2 or more assessments

Not contributing to development of differential diagnosis, diagnostic recommendations

Difficulty explaining case or patient care concepts

Difficulty contributing to group norms (showing interest and effort, active listening, creating space for others to contribute)

Difficulty prioritizing among multiple projects or activities

Difficulty receiving and incorporating feedback

Difficulty accessing and/or effectively utilizing resources for learning

Inadequate preparation for session

Difficulty completing tasks on time

Inconsistent attendance

Disrespectful behavior toward colleagues or patients

Insensitive to diversity in patients, colleagues, or topics

Ineffective or disrespectful communication to patients, families, or colleagues

Other (please explain)

Please explain*

Anticipated Needs*

Select all that apply

Tutoring to improve medical knowledge

Resources to improve time management

Resources to encourage self-directed learning

Coaching to engage in healthy group norms

Coaching to improve communication

Coaching to improve professional behavior

Wellness resources

Improved test-taking strategies

Improved study plan/organization strategies

Other (please explain)

Please explain*

Is this escalation of a previously addressed concern?*

Yes

Is the student being referred following lack of response to email or other contact?*

Yes

Additional Comments*

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