EMT Preceptor Evaluation Form
The STUDENT will complete this form after you have left the clinical/field site. This form is used to provide feedback to staff about your rotation and/or preceptors to ensure that we provide you with a great learning environment. This form and its comments will not effect your grade in any way.
Your Course ID
*
Example: E2024-D6
Student Name
*
Preceptors Name
*
Clinical Location
*
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 4
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 of Clinical
*
-
Month
-
Day
Year
Statement
*
Strongly Disagree
Disagree
Agree
Strongly Agree
My Preceptors's attitude was positive towards the clinical site/ER experience. I felt welcomed at this site.
My orientation to the clinical site/ER was adequate.
My preceptor gave me feedback about my performance.
My preceptor was knowledgeable and shared his or her experience with me.
My preceptor provided a positive learning environment. I had the opportunity to discuss issues.
My preceptor encouraged patient contact and provided effective and discreet educational coaching
I would recommend this preceptor to other students.
Please feel free to comment on any experiences or people who deserve recognition or warrant attention.
The overall impression of your experience with this site is?
*
Unsatisfactory
Poor
Fair
Good
Excellent
Overall
Student Signature
*
Submit
Submit
Should be Empty: