Driver Preceptor Form 2021.01

MCVRS

DRIVER Preceptor Evaluation Form
Date *

Month Day Year
Time *

AM/PM Option
Preceptor: *

First Name Last Name
Preceptor Email *
example@example.com
Preceptor Phone Number *
Please enter a valid phone number.
Preceptee: *

First Name Last Name
Preceptee Email *
example@example.com
Preceptee Phone Number *
Please enter a valid phone number.

Preceptee has current valid: *

	Yes	No
EVOC certification
CPR certification
Drivers License

Precept Date *

Month Day Year
Date
Incident # *

Preceptee demonstrated knowledge *

	Satisfactory	Needs Improvement	Un- satisfactory	Not Applicable
Knowledge of truck functions
Knowledge of truck contents & inventory
Use of checklist

Preceptee driving abilities *

	Satisfactory	Needs Improvement	Un- satisfactory	Not Applicable
Driving returning from hospital
Driving with lights and siren
Driving to hospital with patient

Identifying 1st and 2nd run truck and checking contents *

	Satisfactory	Needs Improvement	Un-satisfactory	Not Applicable
1st Run
2nd Run

Returning truck to service after use *

	Satisfactory	Needs Improvement	Un-satisfactory	Not Applicable
Cleaning, sweeping, and restocking at hospital
Check oxygen and how to change bottle
Replacing used equipment (restocking & where to find at hospital
Cleaning equipment
How to fuel vehicle (to include completing fuel log sheet. Credit card if applicable

Misc. need to know *

	Satisfactory	Needs Improvement	Un-Satisfactory	Not Applicable
Posting call sheet on computer at each building-
Where to plug in computer on each truck
Your password for computer & logging in
How to check each truck for charging
How to reset each truck if not charging
How to communicate with dispatch
Radio channels & how to change to communicate with state helicopter, etc
Procedure for helicopter landing areas
How to read map book
How to use I am Responding app.
How to open drug box on different trucks

Preceptors comments and suggestions: *
Preceptor signature *

Clear
Addendum can be added here:

Cancel of
Upon submission, this form will be sent to MCVRS Captain, 1.LT, and the Preceptor
Should be Empty: