EMT Student Clinical Evaluation Report

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*
Preceptor Name*
Clinical Location*
Date*

MonthDayYear
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: Did the student bring the following equipment with them to the clinical site?*

Equipment On-Hand Comments:
Student Attributes Grading Scale
To rate the student attributes on the scale below, please use these definitions to help guide your choice.

Unacceptable: Work performance was below average. Additional training is a must if the student is to flourish in the work environment. Needs Improvement: Some standards were not met. Additional training is recommended. Meets Expectations: All work standards were met. The quality of the student's work performance is that of a good employee in the normal work environment. Exceeds Expectations: Work performance is exemplary. Student has consistently demonstrated characteristics that will stand out in the normal work environment.

Student Attributes: Please rate the student on the following attributes.*

	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: Works as a team member; is cooperative, assertive, and takes direction from the Team Leader well.
Appearance: Displays appropriate dress, hygiene, and etiquette.
Attitude: Demonstrates a positive attitude towards team members, patients, family members, etc.; appears self-confident, with realistic expectations; is customer focused; and accepts constructive criticism well.
Productivity: Follows safety practices; conserves supplies; keeps work area clean; follows directions and procedures; and actively participates during patient encounters.
Organizational Skills: Demonstrates appropriate management of time and stress; and shows flexibility in handling change.
Communications: Displays appropriate non-verbal (eye contact, body language) and oral (active listening, radio etiquette, grammar) skills.
Cooperation: Displays appropriate leadership skills; appropriately handles criticism, conflicts and complaints; demonstrates problem solving capability; maintains appropriate relationships with supervisors and peers; and follows the chain of command.
Respect: Respects the rights of others; appropriately handles cultural/racial diversity; and does not engage in harassment of any kind.

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 Georgia EMS Licensure Level and you State License Number for verification.*
Preceptor Signature*

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Note to Preceptor: