User:Emilio/sandbox2

Attachment B - Pre-Learning Clinical Confidence Assessment

Learner Identification
Date of Assessment (Year-Month-Day):
Name (First Name, Last Name):
De-Identified Unique Study Code for Learner:
Age (years):
Gender:	🔲 Male 🔲 Female 🔲 Non-Binary
Country of Practice:
Contact Information (email):
Country Code + Phone Number:
🔲 Clinician Status:	🔲 Resident 🔲 Attending Physician 🔲 Attending Surgeon
Discipline/Specialty:	🔲 Medical Officer (Non-Specialist Physician) 🔲 General Surgery 🔲 Neurological Surgery 🔲 Obstetrics and Gynecology 🔲 Ophthalmic Surgery 🔲 Oral and Maxillofacial Surgery 🔲 Otolaryngology 🔲 Pediatric Surgery 🔲 Plastic and Reconstructive Surgery 🔲 Thoracic Surgery 🔲 Urology 🔲 Vascular Surgery 🔲 Other:________________________
Total Years of Post-Fellowship Clinical Practice Experience:
Work Environment:	🔲 Community facility 🔲 Primary health center 🔲 First-level hospital 🔲 Second-level hospital 🔲 Third-level hospital
Total Years of Residency and Fellowship Training Completed:
Clinical Skill To Be Tested:	Modular External Fixation of an Open Tibial Shaft Fracture
Amount of Experience or Training With Modular External Fixation of an Open Tibial Shaft Fracture To Date:

For this pre-learning clinical confidence assessment, please rate your responses from 1-5, with 1 being “Disagree” to 5 being “Agree.

Cognitive
I know how to perform modular external fixation of an open tibial shaft fracture.	Disagree	1	2	3	4	5	Agree
I understand the content of modular external fixation of an open tibial shaft fracture and can demonstrate it to others.	Disagree	1	2	3	4	5	Agree
I can verbally explain the purpose and principle of operating modular external fixation of an open tibial shaft fracture.	Disagree	1	2	3	4	5	Agree
I can verbally explain the sequence and interrelationship between each step.	Disagree	1	2	3	4	5	Agree
Psychomotor
I can precisely imitate the instructed steps and actions of modular external fixation of an open tibial shaft fracture.	Disagree	1	2	3	4	5	Agree
I can smoothly complete the operation steps of modular external fixation of an open tibial shaft fracture.	Disagree	1	2	3	4	5	Agree
I can monitor my modular external fixation of an open tibial shaft fracture for improvements	Disagree	1	2	3	4	5	Agree
I can monitor my modular external fixation of an open tibial shaft fracture operations and make proper adjustments as needed	Disagree	1	2	3	4	5	Agree

Adapted from the L-SES (Learning Self-Efficacy Scale) for Clinical skill assessment described in Kang Y-N, Chang C-H, Kao C-C, Chen C-Y, Wu C-C (2019) Development of a short and universal learning self-efficacy scale for clinical skills. PLoS ONE 14(1): e0209155. https://doi.org/10.1371/journal.pone.020915

Attachment C. Post-Learning Clinical Confidence Assessment

Learner Identification
Date of Assessment (Year-Month-Day):
Name (First Name, Last Name):
De-Identified Unique Study Code for Learner:
Age (years):
Gender:	🔲 Male 🔲 Female 🔲 Non-Binary
Country of Practice:
Contact Information (email):
Country Code + Phone Number:
🔲 Clinician Status:	🔲 Resident 🔲 Attending Physician 🔲 Attending Surgeon
Discipline/Specialty:	🔲 Medical Officer (Non-Specialist Physician) 🔲 General Surgery 🔲 Neurological Surgery 🔲 Obstetrics and Gynecology 🔲 Ophthalmic Surgery 🔲 Oral and Maxillofacial Surgery 🔲 Otolaryngology 🔲 Pediatric Surgery 🔲 Plastic and Reconstructive Surgery 🔲 Thoracic Surgery 🔲 Urology 🔲 Vascular Surgery 🔲 Other:________________________
Total Years of Post-Fellowship Clinical Practice Experience:
Work Environment:	🔲 Community facility 🔲 Primary health center 🔲 First-level hospital 🔲 Second-level hospital 🔲 Third-level hospital
Total Years of Residency and Fellowship Training Completed:
Clinical Skill To Be Tested:	Modular External Fixation of an Open Tibial Shaft Fracture
Amount of Experience or Training With Modular External Fixation of an Open Tibial Shaft Fracture To Date:
Amount of Experience or Training With Modular External Fixation of an Open Tibial Shaft Fracture To Date:
Date Range Over Which the Training Materials Were Accessed (Year-Month-Day to Year-Month-Day):
Hours of Study of Online Materials:
Number of Times Procedure Was Practiced With the Simulator:
Duration of Simulator Practice Time:
Site of Clinical Evaluation (Facility Name, City, Country):
Clinical Evaluator(s):
Number of Procedures in Patients

For this post-learning clinical confidence assessment, please rate your responses from 1-5, with 1 being “Disagree” to 5 being “Agree.”

Cognitive
I know how to perform modular external fixation of an open tibial shaft fracture.	Disagree	1	2	3	4	5	Agree
I understand the content of modular external fixation of an open tibial shaft fracture and can demonstrate it to others.	Disagree	1	2	3	4	5	Agree
I can verbally explain the purpose and principle of operating modular external fixation of an open tibial shaft fracture.	Disagree	1	2	3	4	5	Agree
I can verbally explain the sequence and interrelationship between each step.	Disagree	1	2	3	4	5	Agree
Psychomotor
I can precisely imitate the instructed steps and actions of modular external fixation of an open tibial shaft fracture.	Disagree	1	2	3	4	5	Agree
I can smoothly complete the operation steps of modular external fixation of an open tibial shaft fracture.	Disagree	1	2	3	4	5	Agree
I can monitor my modular external fixation of an open tibial shaft fracture for improvements	Disagree	1	2	3	4	5	Agree
I can monitor my modular external fixation of an open tibial shaft fracture operations and make proper adjustments as needed	Disagree	1	2	3	4	5	Agree

Adapted from the L-SES (Learning Self-Efficacy Scale) for Clinical skill assessment described in Kang Y-N, Chang C-H, Kao C-C, Chen C-Y, Wu C-C (2019) Development of a short and universal learning self-efficacy scale for clinical skills. PLoS ONE 14(1): e0209155. https://doi.org/10.1371/journal.pone.0209155