T.

LOUS HIGHER INSTTTOTE OF

SLouis
MEDICAL STUDIES DOUALA
(B MINISTRY OF HIGHER EDUCATION AUTHORIZATION
MINISTRY OF PUBLIC HEALTH AUTHORIZATION
No 05/0010O/MINESUP OF 12/01/05 and No 06/ 0056/MINESUP of 02/06/2006
NO 0421/D/MSPICAB OF 06/09/04 MINSANTE

PRIME MINISTER'S VISA: 001143 OF 18" MAY 2006

INTERENSHIP EVALUATION FORM

Student's Name:
DIPOEO NGAnes EBOINE BACMat. No 11Dt13)262
Department_IDLfEAY
Clinical Area ad Pio HoStal
Date: From Augua To Salenber
CHARACTER
1. RELIABILITY 3. OBSERVATIONN
Very reliable (4) Very observant (4)
Reliable 3 Observant (3)
Fairly reliable
(2) Fairly observant (2)
May be reliable
(1) May be observant (1)
Unreliable (0) Unobservant (0)
2. STUDENT/PEER RELATIONSHIP 4. TEAM SPIRIT
Cheerful and Respectful (4) Very cooperative (4)
Cheerful
Co-operative (3
Argumentative (2) Fairly cooperative (2)
Aggressive (1) May be cooperative 1)
Insolent (0) Uncooperative (0)

PROFESSIONAL QUALITY
5. PUNCTUALITY 8. INITLATIVE
Always punctual (4) Very Initiative 4)
Fairly punctual (3) Initiative (3)
Sometimes interested (2) Sometimes Initiative (2)
Never punctual (1) Works only when assigned (1)
Absence (0)
6. PROFESSIONAL ATTITUDE 9. PROFESSIONAL SKILLS
Devoted (4) Very good (4)
Fairly good (3) Good (3)
Interested (2) Fair (2)
Sometimes interested (1) Poor (1)
Disinterested (0) Very poor
(0)
7. STUDENT/PATIENT RELATIONSHIP 10. PERSONAL APPEARANCE
Patient and reassuring (4) Very neat and smart (4)
Concerned (3) Neat and smart (3)
Impatient (2) Carelessly dressed (2)
Harsh (1) Untidy (1)
Disconcerted (O) Dirty (0)

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 PLEASE TICK THE APPROPRIATE BOX

General Remarks
Exceptional Student
Good Student
Average Student
Poor Student

COMMENTS:

Sho iS aq00d buut S en mcky and

no Skauqht koLdard: Plaase hotp_bas be
Sin c2e

Number of Night Duties:

Number of Days on Sick Leave

Number of Days Absent: .

SIGNATURE OF STUDENT

EVALUATING OFFICER'S CONTACT

Name
Position: Phone number

Signature:)
NB: This Evaluation Form must be sealed in a stamped envelope after the signature of the

evaluating officer

www.stlouisbdouala.com
 MEDICAL STUDIES DOUALA
MINISTRY OF HIGHER EDUCATION AUTHORIZATION
MINISTRY OF PUBLIC HEALTH AUTHORIZ
No 05/0010MINESUP OF 12/01/05 and No 06 I 0056/MINESUP of 02/06/2006
NO 0421/D/MSPICAB OF O6/09/04 MINSANTE

PRIME MINISTER'S VISA: 001143 OF 18 MAY 2006

INTERENSHIP EVALUATION FORM

Student's Name: no Emeu 1ebo Mat. No AKGIKlOA3

Department Nursnaa
Clinical Area
Daut ucsg Pio_HospitalAKwa-Nor
Date: From
Auqust c90 ToHth plmbor a0
CHARACTER
1. RELIABILITY 3. OBSERVATION
Very reliable (4) Very observant (4)
Reliable (3) Observant (3
Fairly reliable (2) Fairly observant (2)
May be reliable (1) May be observant (1)
Unreliable (0) Unobservant (0)
2. STUDENT/PEER RELATIONSHIP 4. TEAM SPIRITr
Cheerful and Respectful (4 Very cooperative (4)
Cheerful (3) Co-operative (3)
Argumentative (2) Fairly cooperative (2)
Aggressive (1) May be cooperative (1)
Insolent (0) Uncooperative (0)

PROFESSIONAL QUALITY
5. PUNCTUALITY 8. INITIATIVE
Always punctual (4) Very Initiative 4)
Fairly punctual (3) Initiative (3)
Sometimes interested (2) Sometimes Initiative (2)
Never punctual (1) Works only when assigned (1)
Absence (0)
6. PROFESSIONAL ATTITUDE 9. PROFESSIONAL SKILLs
Devoted (4 Very good (4)
Fairly good (3) Good (3)
Interested (2) Fair (2)
Poor (1)
Sometimes interested (1)
Disinterested (0) Very poor (0)
7. STUDENT/PATIENT RELATIONSHIP 10. PERSONAL APPEARANCE
Patient and reassuring 4) Very neat and smart (4)
Concerned (3 Neat and smart (3
Impatient (2) Carelessly dressed (2)
Harsh (1) Untidy (1)
Disconcerted (0) Dirty (0)

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 PLEAS TICK TIE APPROPRIATE BOX
H
SN

General Remarks
Exceptional Student
Good Student

Average Student
UPoor Student

COMMENTS:
Cal Peisonol
Con m a k e CA C O medi about
Seno
but Sho neods to Smart nd
Prachcaus

Number of Night Duties:

Number of Days on Sick Leave:

Number of Days Absent:

SIGNATURE OF STUDENT

EVALUATING OFFICER'S CONTACT

Name
Position: Phone number:

Signature
NB: This Evaluation Form must be sealed in a stamped envelope after the signature of the
evaluating officer.

www.stlouisbdouala.com
 INTERENSHIP EVALUATION FORM

Student's Nanme: NuhoNGE BEATE Mat. No Hlialous

Department PeARmtC
Clinical Area Si Tadhe Po tHosPiaL AFhula NORO
Date: From sl0la090 To Hl9lo090
CHARACTER

1. RELIABILITY 3. OBSERVATION
VeryVery reliable (4) Very observant (4)
Reliable (3) Observant (3)
Fairly reliable (2) Fairly observant (2)
May be reliable
(1) May be observant (1)
Unreliable (0) Unobservant (0)
2. STUDENT/PEER RELATIONSHIP 4. TEAM SPIRIT
Cheerful and Respectful (4) Very cooperative (4)
Cheerful (3) Co-operative (3)
Argumentative (2) Fairly cooperative (2)
Aggressive (1) May be cooperative (1)
Insolent (0) Uncooperative (0)

PROFESSIONAL QUALITY
5. PUNCTUALITY 8. INITIATIVE
Always punctual (4) Very Initiative (4)
Fairly punctual (3) Initiative (3)
Sometimes interested (2) Sometimes Initiative (2)
Never punctual (1) Works only when assigned (1)
Absence (0)
6. PROFESSIONAL ATTITUDE 9. PROFESSIONAL SKILLS
Devoted (4) Very good (4)
Good (3)
Fairly good (3)
Interested (2) Fair (2)
Sometimes interested (1) Poor (1)
Disinterested (0) Very poor (0)
7. STUDENT/PATIENT RELATIONSHIP 10. PERSONAL APPEARANCE
Patient and reassuring (4) Very neat and smart (4)
Concerned (3) Neat and smart (3)
Impatient (2) Carclessly dresscd (2)
Harsh (1) Untidy (1)
Disconcerted (0) Dirty (0)

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 PLEASE TICK TI

General Remarkks

Exceptional Student

Good Student
Average Student

Poor Student

COMMENTS:
h eoh
healHh Per sonel
mace a guod
She Con
pperlu folloed up

Number of Night Duties:

Leave:
Number of Days on Sick
Number of Days Absent:

SIGNATURE OF STUDENT

EVALUATING OFFICER'S CONTACT

Name:
Phone number:
Position:

Signature:
NB: This Evaluation Form must be sealed in a stamped envelope after the signature of the
evaluating officer.

www.stlouisbdouala.com
 NSTITUTE OF
Louis
MEDICAL STUDIES DOUALA
MINISTRY OF HIGHER EDUCATION AUTHORIZATION
No 05/0010MINESUP OF 12/01/05 and No 06/ 0056/MINESUP
MINISTRY OF PUBLIC HEALTH AUTHORIZATION
of 02/06/2006 NO 0421/DIMSPICAB OF 06/09/04MINSANTE
PRIME MINISTER'S VISA: 001143 OF 18 MAY 2006

INTERENSHIP EVALUATION FORM1

Student's Name: E G ZACLINE AcHu_Mat. No_NSGT7bgo
Department NußSiNG
Clinical Area
HOPITAL SALNI ADRE Pio
Date: From Auqust To h hSEPTEMBER
CHARACTER
1. RELIABILITY 3. OBSERVATION
Very reliable (4) Very observant (4)
Reliable 3) Observant (3)
Fairly reliable (2) Fairly observant (2)
May be reliable (1) May be observant (1
Unreliable (0) Unobservant (0)
2. STUDENT/PEER RELATIONSHIP 4. TEAM SPIRIT
Cheerful and Respectful (4) Very cooperative 4)
Cheerful (3) Co-operative 3)
Argumentative 2) Fairly cooperative (2)
Aggressive (1) May be cooperative (1)
Insolent (0) Uncooperative (0)

PROFESSIONAL QUALITY
5. PUNCTUALITY 8. INITIATIVE
Always punctual (4) Very Initiative (4)
Fairly punctual (3) Initiative (3)
Sometimes interested
(2) Sometimes Initiative (2)
Never punctual(1 Works only when assigned (1)
Absence (0)
6. PROFESSIONAL ATTITUDE 9. PROFESSIONAL SKILLS
Devoted (4) Very good 4)
Fairly good (3) Good (3)
Interested (2) Fair (2)
Sometimes interested (1) Poor (1)
Disinterested (0) Very poor (0)
7. STUDENT/PATIENT RELATIONSHIP 10. PERSONAL APPEARANCE
Patient and reassuring (4) Very neat and smart (4)
Concerned (3) Neat and smart (3)
Impatient (2) Carelessly dressed (2)
Harsh (1) Untidy (1)
Disconcerted (0) Dirty (0)

www.stlouisbdouala.com
 PLEASE TICK THE APPROPRIATE BOOX

General Remarks
UALA
Exceptional Student
Good Student
Average Student
Poor Student

COMMENTS:

Number of Night Duties:

Number of Days on Sick Leave:

Number of Days Absent

SIGNATURE OF STUDENT

EVALUATING OFFICER'S CONTACT

Name:

Position Phone number:

Signature
NB: This Evaluation Form must be sealed in a stamped envelope after the signature of the
evaluating officer.

www.stlouisbdouala.com
 ST. LOUIS HIGHER INSTITUTE OF
MEDICAL STUDIES DOUALA
MINISTRY OF HIGHER EDUCATION AUTHORIZATION
No 05/001OMINESUP OF 12/01/05 and No 06/ 0056/MINESUP MINISTRY OF PUBLIC HEALTH
of 02/06/2006 AUTHORIZATION
NO 0421/DIMSPICAB OF
06/09/04 MINSANTE
PRIME MINISTER'S VISA: 001143 OF 18 MAY 2006

Student's Name:
INTERENSHIP EVALUATION FORM

xtnkalatha SRin{u_ Mat. No

GHER
S619t120o
DepartmentNUanC
Clinical Area
adro 0
Date: FromD3loZ/2020_ To O A12620
CHARACTER
1. RELIABILITY 3. OBSERVATION
Very reliable (4 Very observant (4)
Reliable (3) Observant (3)
Fairly reliable (2) Fairly observant 2)
May be reliable
(1) May be observant (1)
Unreliable (0) Unobservant (0)
2. STUDENT/PEER RELATIONSHIP 4. TEAM SPIRIT
Cheerful and Respectful (4)J
Very cooperative (4)
Cheerful (3) Co-operative (3)
Argumentative (2) Fairly cooperative (2)
Aggressive (1) May be cooperative (1)
Insolent (0) Uncooperative (0)

PROFESSIONAL OUALITY
5. PUNCTUALITY 8. INITIATIVE
Always punctual1 (4) Very Initiative 4)
Fairly punctual (3) Initiative 3)
Sometimes interested (2) Sometimes Initiative 2)
Never punctual (1) Works only when assigned (1)
Absence (0)
6. PROFESSIONALATTITUDE 9. PROFESSIONAIL SKILLS
Devoted (4) Very good (4)
Fairly good (3 Good (3)
Interested (2) Fair (2)
Sometimes interested (1) Poor (1)
Disinterested (0) Very poor (0)
7. STUDENT/PATIENT RELATIONSHIP 10. PERSONAL APPEARANCE
Patient and reassuring (4) Very neat and smart (4
Concerned 3) Neat and smart (3)
Impatient (2) Carclessly dressed (2)
Harsh (1) Untidy (1)
Disconcerted (0) Dirty (0)

www.stlouisbdouala.com
 PLEASE TICK THE APPROPRIATE BOX

General Remarks
Exceptional Student
Good Student
Average Student
Poor Student

COMMENTS:

Con mace a
Con qond odica esono

Number of Night Duties:

Number of Days on Sick Leave:

Number of Days Absent:

SIGNATURE OF STUDENT

EVALUATING OFFICER'S CONTACT

Name
Position: Phone number:
Signature:
NB: This Evaluation Form must be sealed in a stamped envelope after the signature of the
evaluating officer.

www.stlouisbdouala.com
 ST. LOUIS HIGHER INSTITU E OF
MEDICAL STUDIES DOUALA
B MINISTRY OF HIGHER EDUCATION AUTHORIZATION MINISTRY OF PUBLIC HEALTH AUTHORIZATION
No 05/0010MINESUP OF 12/01/05 and No 06/ 0056/MINESUP of 02/06/2006 NO 0421/D/MSPICAB OF 06/09/04 MINSANTE

PRIME MINISTER'S VISA: 001143 OF 18 MAY 2006

INTERENSHIP EVALUATION FORM

Student's Name: N ecuous Agi Mat. No SLLAICA*

DepartmentNursinq
Clinical Area tDrITALStrAAAE PiD
Date: From 03" Auguut ToD Seltemb 010
CHARACTER
1. RELLABILITY 3. OBSERVATION
Very reliable
(4) Very observant (4)
Reliable (3) Observant (3)
Fairly reliable (2) Fairly observant (2)
May be reliable (1) May be observant (1)
Unreliable (0) Unobservant (0)
2. STUDENT/PEER RELATIONSHIP 4. TEAM SPIRIT
Cheerful and Respectful (4) Very cooperative (4)
Cheerful 3) Co-operative (3
Argumentative (2) Fairly cooperative (2
Aggressive (1) May be cooperative (1)
Insolent (0) Uncooperative (0)

PROFESSIONAL QUALITY
5. PUNCTUALITY 8. INITIATIVE
Always punctual (4 Very Initiative (4)
Fairly punctual (3) Initiative (3)
(2) Sometimes Initiative (2)
Sometimes interested
Never punctual (1) Works only when assigned (1)
Absence (0)
6. PROFESSIONALATTITUDE 9. PROFESSIONAL SKILLSS
Devoted (4) Very good (4)
Fairly good (3) Good (3)
Interested Fair (2)
(2)
Sometimes interested (1) Poor (1)
Disinterested (0) Very poor
(0)
7. STUDENT/PATIENT RELATIONSHIP 10. PERSONAL APPEARANCE
Patient and reassuring (4) Very neat and smart (4)
Concened (3 Neat and smart (3)
Impatient (2) Carclessly dressed (2)
Harsh (1) Untidy (1)
Disconcerted (0) Dirty (0)

www.stlouisbdouala.com
 PLEASE TICK THE APPROPRIATE BOX

General Remarks 9H STnon

S
Exceptional Student
Good Student
Average Student
Poor Student

COMMENTS
Udd

Can be a medica eone we)

ollnlued up

Number of Night Duties:

Number of Days on Sick Leave:

Number of Days Absent:

SIGNATURE OF STUDENT

EVALUATING OFFICER'S CONTACT

Name:

Position Phone number:

Signature:
NB: This Evaluation Form must be sealed in a stamped envelope after the signature of the

evaluating officer.

www.stlouisbdouala.com
 MEDICAL STUDIES DOUALA
MINISTRY OF PUBLIC HEALTH AUTHORIZATION
AUTHORIZATION
MINISTRY OF HIGHER EDUCATION NO 0421/DIMSPICAB OF 06/09/04 MINSANTE
05/001OMINESUP OF 12/01/05
and No 06/ 0056/MINESUP of 02/06/2006
No
2006
PRIME MINISTER'S VISA: 001143 OF 18 MAY

INTERENSHIP EVALUATION FORM

No MITI1111
Student's Name: KERSHA MBONGO NAANA_Mat.
Departmentedlical lmaqin lechniqus MIT
Clinical Area Hopitd_St fodre Po d Dauala
hSeptamher2020
Date: From rd Auaust To
CHARACTER

3. OBSERVATION
1. RELIABILITY
Very observant (4)
Very reliable (4)
Observant (3)
Reliable (3)
Fairly observant (2)
Fairly reliable (2)
May be observant (1)
May be reliable (1)
Unobservant (0)
Unreliable (0)
4. TEAM SPIRIT
2. STUDENT/PEER RELATIONSHIP
Very cooperative 4)
Cheerful and Respectful 4)
Co-operative (3)
Cheerful (3)
Fairly cooperative (2)
Árgumentative (2)
May be cooperative (1)
Aggressive (1)
Uncooperative (0)
Insolent (0)

PROFESSIONAL QUALITY
8. INITIATIVE
5. PUNCTUALITY
Very Initiative (4)
Always punctual (4)
Initiative (3)
Fairly punctual (3) Sometimes Initiative (2)
Sometimes interested (2) Works only when assigned ()
Never punctual (1)
Absence (0) 9. PROFESSIONAL SKILLS
6. PROFESSIONALATTITUDE
Very good (4)
Devoted 4) Good (3)
(3) (2)
Fairly good Fair
Interested (2) (1)
Poor
Sometimes interested (1) 0)
Very poor
Disinterested (0) 10. PERSONAL APPEARANCE
7. STUDENT/PATIENT RELATIONSHIP
Very neat and smart 4)
Patient and reassuring 4) Ncat and smart (3)
Concerned (3) Carelessly dressed (2)
Impatient (2) (1)
Untidy
Harsh (1) (0)
Dirty
Disconcerted (0)
www.stlouisbdouala.com
 PLEASE TICK THE APPROPRIATE BOX

General Remarks
Exceptional Student
Good Student
Average Student
Poor Student

COMMENTS:

Number of Night Duties:

Number of Days on Sick Leave:

Number of Days Absent:

SIGNATURE OF STUDENT

EVALUATING OFFICER'S CONTACT

Name

Position: Phone number:

Signature:
NB: This Evaluation Form must be sealed in a stamped envelope after the signature of the
evaluating officer.

www.stlouisbdouala.com