MCVRS
EMT Preceptor Evaluation Form
Date
*
/
Month
/
Day
Year
Time
*
AM
PM
AM/PM Option
Preceptor:
*
First Name
Last Name
Preceptor Email
*
example@example.com
Preceptor Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preceptee:
*
First Name
Last Name
Preceptee Email
example@example.com
Preceptee Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Precept Date
*
/
Month
/
Day
Year
Date
Incident #
*
Preceptee role:
*
Lead (AIC)
ALS assist
BLS assist
Other
If "Other" then explain:
*
Affective Domain Evaluation
How did the EMT preceptee perform mentally during the incident?
*
Rows
Satisfactory
Needs Improvement
Un-
satisfactory
Not Applicable
Preparedness
Appearance
Attitude/behavior
Accepts feedback
Self-motivation
Safety precautions
Relationship/ communication w. patient
Relationship/teamwork w. preceptor
Cognitive Domain Evaluation
How did the EMT preceptee perform with their knowledge of EMS during the incident?
*
Rows
Satisfactory
Needs Improvement
Un-
satisfactory
Not Applicable
Obtained chief complaint
Completed a medical assessment
Completed a trauma assessment
BLS care provided
Radio/phone medical report
Verbal report to medical staff (ER)
Incident documentation
Psycomotor Domain Evaluation
How did the EMT preceptee perform any necessary skills, during the incident, and do them in the best interest of the patient?
*
Rows
Satisfactory
Needs Improvement
Un-
satisfactory
Not Applicable
Patient assessment skills
Oxygen therapy
Medication administration
Trauma care
Medical care
Preceptors comments and suggestions:
*
Preceptor signature
Addendum can be added here:
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Upon submission, this form will be sent to MCVRS Captain, 1.LT, and the Preceptor
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