MCVRS
DRIVER 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.
Preceptee has current valid:
*
Rows
Yes
No
EVOC certification
CPR
certification
Drivers
License
Precept Date
*
/
Month
/
Day
Year
Date
Incident #
*
Preceptee demonstrated knowledge
*
Rows
Satisfactory
Needs Improvement
Un-
satisfactory
Not Applicable
Knowledge of truck functions
Knowledge of truck contents & inventory
Use of checklist
Preceptee driving abilities
*
Rows
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
*
Rows
Satisfactory
Needs Improvement
Un-satisfactory
Not Applicable
1st Run
2nd Run
Returning truck to service after use
*
Rows
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
*
Rows
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
*
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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