Medical Student Evaluation Form

You have the option of including your September 2008 rotation in your Medical Student Performance Evaluation (MSPE) only if you request it by August 1, 2008. To do so, fill out the information below and hit submit. A copy will be sent to you for your records. If you do not receive a verifying e-mail, please resubmit.

When you review your MSPE, there will be a notation stating “Requested September (name of) rotation.” Those evaluations are usually available by mid-October. If you change your mind about including your September evaluation, e-mail susan.leonhart@osumc.edu as soon as possible.

First Name
Middle Name
Last Name		Note: If your last name consists of two or more words, e.g., "Van Beethoven," please use an underscore ("Van_Beethoven") as a separator, rather than a space.

Phone	Pager	E-mail (Enter your full valid OSU e-mail address, e.g., firstname.lastname@osumc.edu)

PLEASE ANSWER THE FOLLOWING QUESTIONS:

Full name of September Rotation:
(do not use course numbers)

If rotation is outside the state of Ohio,
give name of facility, city, and state:

Questions? Contact: Susan Leonhart (292-6450) or susan.leonhart@osumc.edu