Skills, Patient Contacts, Field/Clinical Hours & Evaluation Request
(to be Completed by Students in the 2024-2025 Cohort)
Select your program
*
C-Shift
Evening
Reciprocity Residents
A Shift
*
Please Select
None
ZZAdjust
Reciprocity Candidates
Please Select
Shum
Gul
ZZAdjust
C Shift
*
Please Select
Aman
Elhamdani
Flynn
Hooper
Huber
Metz
Morper
Reedy
Stokes
Tax
ZZAdjust
Evening
*
Please Select
Biehl
Herzig
Krysmalski
Nguyen
Polla
Rosenberg
Stowe
Walter
Washington
ZZAdjust
What do you want to submit?
*
Skills
Clinical hours
Patient contacts
No skills performed
No patient contacts
Did not ride - Took Leave - DFRS
Did not ride - Detailed to OPS
Did not ride - Volunteer
Reciprocity orientation
Where were you?
*
ED
OR
MSP
AFRA
Medic
Cath Lab
Chase Car
Classroom
Pediatrics
Geriatrics
Obstetrics
Psychiatric
EMS DO
PSCC
Skills and patient contacts encountered on
*
-
Month
-
Day
Year
Date Picker Icon
Who or what did you perform the skills on?
*
Task trainer
High fidelity simulator
Animal cadaver
Human cadaver
Live human
Other
Which skills did you perform?
*
Vascular access
Medication administration
Airway management
Diagnostic test
Electrical therapy
Vascular Skills
*
Rows
Number Performed
IV attempt
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IV successful
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IO attempt
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IO successful
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EJ attempt
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EJ successful
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Blood draw
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Medication Administration
*
Rows
Number Performed
IV bolus
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IV drip
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Nebulizer
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Sublingual
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Oral
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Intranasal
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Intramuscular
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Topical
0
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Subcutaneous
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Airway Management
*
Rows
Number Performed
BVM
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ETI attempt
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ETI success
0
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CPAP
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NTI attempt
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NTI success
0
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NGT
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NDT
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Cric needle
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Cric surgical
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Diagnostics
*
Rows
Number Performed
Capnography
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Glucometer
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3-lead EKG
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12-lead EKG
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Electrical therapies
*
Rows
Number Performed
Defibrillation
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Transcutaneous Pacing
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Synchronized Cardioversion
0
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What was the patient's age? (You may select more than one option if you are entering multiple patients)
*
Newborn (birth-1 mo)
Infant (2 mo-1 year)
Toddler (1 year-2)
Preschooler (3-5)
School Age (6-12)
Adolescent (13-18)
Adult (19-60)
Geriatric (60+)
Newborn - Select the number of patients you made contact with for the respective chief complaint.
*
Rows
Number of Patients - Newborn
Syncope
1
2
3
4
5
6
7
8
9
10
11
12
13
14
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17
18
19
20
Endocrine
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Chest Pain
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Respiratory
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Reproductive
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Genitourinary
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Integumentary
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Cardiovascular
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Musculoskeletal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Gastrointestinal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Immune and Lymph
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Altered Mental Status
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Nervous (include psych)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Infant - Select the number of patients you made contact with for the respective chief complaint.
*
Rows
Number of Patients - Infant
Syncope
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Endocrine
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Chest Pain
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Respiratory
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Reproductive
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Genitourinary
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Integumentary
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Cardiovascular
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Musculoskeletal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Gastrointestinal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Immune and Lymph
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Altered Mental Status
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Nervous (include psych)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Toddler - Select the number of patients you made contact with for the respective chief complaint.
*
Rows
Number of Patients - Toddler
Syncope
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Endocrine
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Chest Pain
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Respiratory
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Reproductive
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Genitourinary
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Integumentary
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Cardiovascular
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Musculoskeletal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Gastrointestinal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Immune and Lymph
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Altered Mental Status
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Nervous (include psych)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Preschooler - Select the number of patients you made contact with for the respective chief complaint.
*
Rows
Number of Patients - Preschooler
Syncope
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Endocrine
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Chest Pain
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Respiratory
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Reproductive
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Genitourinary
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Integumentary
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Cardiovascular
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Musculoskeletal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Gastrointestinal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Immune and Lymph
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Altered Mental Status
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Nervous (include psych)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
School age - Select the number of patients you made contact with for the respective chief complaint.
*
Rows
Number of Patients - School Age
Syncope
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Endocrine
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Chest Pain
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Respiratory
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Reproductive
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Genitourinary
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Integumentary
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Cardiovascular
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Musculoskeletal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Gastrointestinal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Immune and Lymph
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Altered Mental Status
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Nervous (include psych)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Adolescent - Select the number of patients you made contact with for the respective chief complaint.
*
Rows
Number of Patients - Adolescent
Syncope
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Endocrine
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Chest Pain
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Respiratory
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Reproductive
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Genitourinary
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Integumentary
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Cardiovascular
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Musculoskeletal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Gastrointestinal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Immune and Lymph
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Altered Mental Status
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Nervous (include psych)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Adult - Select the number of patients you made contact with for the respective chief complaint.
*
Rows
Number of Patients - Adult
Syncope
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Endocrine
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Chest Pain
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Respiratory
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Reproductive
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Genitourinary
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Integumentary
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Cardiovascular
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Musculoskeletal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Gastrointestinal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Immune and Lymph
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Altered Mental Status
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Nervous (include psych)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Geriatric - Select the number of patients you made contact with for the respective chief complaint.
*
Rows
Number of Patients - Geriatrics
Syncope
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Endocrine
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Chest Pain
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Respiratory
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Reproductive
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Genitourinary
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Integumentary
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Cardiovascular
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Musculoskeletal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Gastrointestinal
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Immune and Lymph
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Altered Mental Status
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Nervous (include psych)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Enter the date and time you arrived at the clinical site.
*
-
Month
-
Day
Year
Date Picker Icon
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
10
20
30
40
50
Minutes
Enter the date and time you left the clinical site.
*
-
Month
-
Day
Year
Date Picker Icon
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
10
20
30
40
50
Minutes
Total clinical hours
*
Enter the total hours spent in the clinical setting rounded to the nearest quarter hour.
Enter the charge paramedic's email address with whom you worked today
*
Enter the preceptor's email address with whom you worked today
*
Your evaluation of the preceptor. Note - preceptor does NOT receive this; your submission is completely anonymous.
Rows
Agree
Disagree
Not Observed
Knowledge: associates pathophysiology with patient condition; helps assess patients; promotes application of classroom knowledge to clinical setting
Communication: professional; conveys ideas clearly; actively listens; non-judgmental
Critical Thinking: follows established policies and procedures; demonstrates effective problem solving skills
Caring: culturally sensitive, ethical, professional
Teaching: expresses interest in preceptor role; enthusiastic about sharing knowledge; able to explain things in simple format
Other: arrived on time; on site the entire assigned period; in uniform; provides a safe environment
Please elaborate on any "Disagree". Your preceptor will NOT read your submission.
Please use the space below to provide any additional information you wish to share with Academy staff.
student email
Submit
Should be Empty: