Advanced EMT Student Clinical Evaluation Report
This form is to be filled out by the PRECEPTOR of your Clinical/Field shift. This form will provide feedback to the Instructor and Administrative Staff to ensure our students adhere to the guidelines set before them. By completing this evaluation, you provide us the opportunity to better our students in areas in which they may need assistance. REMEMBER, this student may become your next partner.
Student Name
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Preceptor Name
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Clinical Location
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Please Select
Station 2 - Community Ambulance Service
Station 3 - Community Ambulance Service
Station 5 - Columbus Fire and EMS
Station 7 - Community Ambulance Service
Station 8 - Columbus Fire and EMS
Station 9 - Columbus Fire and EMS
Post 22 - Community Ambulance Service
First Response
CARE - Phenix City
AMR - Medic 1
AMR - Medic 2
AMR - Medic 3
AMR - Medic 5
AMR - Medic 6
Macon County - M1
Macon County - M2
Meriwether County EMS - M1
Meriwether County EMS - M12
Other (Not listed - Identify in Comments)
Date
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-
Month
-
Day
Year
Clinical/Field Category
*
Please Select
Field: Ambulance
Field: MFR
Clinical (In an approved facility)
Capstone Field Internship
Note to Preceptor:
Thank you for taking the time to assist this student in his/her clinical/field rotation. Without preceptors, our students miss out on a valuable learning experience. Without your feedback, we cannot adequately evaluate them and work on areas where improvement is needed. Please take a moment to complete this evaluation to assist us in helping our students achieve completion of this course. STUDENTS ARE NOT PROVIDED A COPY OF THIS EVALUATION.
Equipment On-Hand:
*
Yes
No
Proper Uniform
ID Badge
Stethoscope
Clinical Folder/Forms
EMT Text/Notebook
Equipment On-Hand Comments:
Student Attributes
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Unacceptable
Needs Improvement
Meets Expectations
Exceeds Expectations
Attendance - Arrives and leaves on time.
Character -Displays loyalty, honesty, trustworthiness, dependability, reliability, initiative, self-discipline and self-responsibility
Teamwork
Appearance
Attitude
Productivity
Organizational Skills
Communications
Cooperation
Respect
Student Attribute Comments:
Please give us any additional feedback, whether good, bad, or indifferent, which you believe the Staff should be made aware of. Once again remember, this maybe your next employee or partner.
Any skills which the student needs remediation on?
Please provide your State of EMS Licensure and you State License Number for verification.
*
Signature
*
Submit
Submit
Should be Empty: