THIKA SCHOOL OF MEDICAL AND HEALTH SCIENCES

DEPARTMENT OF HUMAN NUTRITION AND DIETETICS

INDUSTRIAL SUPERVISOR FEED BACK FORM

STUDENTS NAME
________________________________________________________________

ADMISSION NUMBER

NAME & TITLE OF SUPERVISOR

_____________________________________________________

EMAIL OF SUPERVISOR
____________________________________________________________

ORGANIZATION
__________________________________________________________________

1. Rate the attaché’s performance during Attachment

□Excellent □Very Good □Satisfactory □Needs Improvement □ Unsatisfactory

2. Rate the attaché positively represented Human Nutrition Department and Thika School of
Medical and Health Sciences:

□Excellent □Very Good □Satisfactory □Needs Improvement □ Unsatisfactory

2. Describe how the attaché’s performance benefited your company:

3. What were the attaché’s strengths?

4. In what areas could the attaché improve?

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 THIKA SCHOOL OF MEDICAL AND HEALTH SCIENCES

DEPARTMENT OF HUMAN NUTRITION AND DIETETICS

INDUSTRIAL SUPERVISOR FEED BACK FORM

5. Rate the attaché’s preparation for the attachment:
□Excellent □Very Good □Satisfactory □Needs Improvement □Unsatisfactory

6. What would you specifically recommend to better prepare our attachés

7. Your overall rating of the Nutrition Department of Thika School of Medical and health
Sciences attachment program:

□Excellent □Very Good □Satisfactory □Needs Improvement □ Unsatisfactory

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 THIKA SCHOOL OF MEDICAL AND HEALTH SCIENCES

DEPARTMENT OF HUMAN NUTRITION AND DIETETICS

INDUSTRIAL SUPERVISOR FEED BACK FORM

Supervisor’s confidential report

Supervisors Checklist to be filled at the end of each week (The supervisor is the person working
closely with the student in each of the areas)

In a scale of 1-5, rate the student’s quality of practice and conduct

1-poor, 2-improve, 3 Fair, 4- Good, 5-excellent

Attribute 5 4 3 2 1

1. Always ready to instruct and supervise those under him/her.

2. Reports on duty punctually and remains available.

3. Establishes and maintains good relationship with the

patient/client and the health care team through effective
communication skills.

4. Always aware and observes the expected behaviors/rules,

regulations and policies of the institution/organization and
profession.

5. Appears neat and well-groomed in appropriate uniform as

required.

6. Acts reliably and honestly as client’s advocate

7. Calm and effective even when under pressure of work.

8. Always ready to learn more and eager to extend and apply

new professional concepts appropriately.

9. Always innovative, alert and prompt in making appropriate

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 THIKA SCHOOL OF MEDICAL AND HEALTH SCIENCES

DEPARTMENT OF HUMAN NUTRITION AND DIETETICS

INDUSTRIAL SUPERVISOR FEED BACK FORM

decisions.

10. Demonstrates interaction and synthesis of knowledge for

quality care.

11. Collects relevant patients/clients data records accurately.

12. Interprets the patient’s /client’s data and formulates nutrition

care plan unique to patient/client/family/community.

13. Professionally prepares/counsels patient/ family/community

for patient’s discharge/follow-up care.

14. Practices effective counseling skills

15. Conducts nutrition assessments appropriately.

16. Determines priority needs collaboratively with

patient/client/family/community.

17. Initiates a plan of care collaboratively With patient/family

health providers Utilizing available resources.

18. Implements nutrition care plan and keeps records

19. Maintains patient/client privacy and Confidentiality

20. Evaluates the effectiveness of nutrition interventions and

makes necessary adjustments.

TOTAL (%)

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 THIKA SCHOOL OF MEDICAL AND HEALTH SCIENCES

DEPARTMENT OF HUMAN NUTRITION AND DIETETICS

INDUSTRIAL SUPERVISOR FEED BACK FORM

Strong points observed:

______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________

Suggestions for improvement:

Supervisor’s recommendations:

Comment by student on attachment:

Sign (supervisor) _________________

Official stamp for the institution________________

Date_____________________________________

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