ALS PDI Authorization, Logbook, and Evaluation Form
Please complete this form for all of your ALS PDI experience. Use this form to attest to your hours as well.
Is this a PSTA sponsored class
Yes
No
Have you applied for PDI Approval yet?
*
Please Select
Yes
No
If this field was auto populated do not change!
Input your First and Last Name
*
First Name
Last Name
Enter Email Address
*
example@example.com
Best Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Class Title
*
Please Select
Core Class
EMS Journal Club
Field Training
Grand Rounds
Remedial Compliance Class
Webinar
Other
If "Other Class Title" Please List
Class Location
*
Please Select
PSTA
FRS Fire Station
PSHQ
Online
Other (Please specify in next box)
The web link to the course (if online)
If "Other Location" Please List
This class was held at FRS station
blanks
.
Lead Instructor's Name
*
Date of the Class
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Was this course preapproved through the PSTA?
*
Please Select
Yes
No
Who approved the course?
What was your Course Approval number?
What did you think about the Artificial Intelligence (AI) in our simulated patient? Did you like the scenario and how it was used?
*
Please Provide Candid Feedback
*
Rows
Very Good
Good
Fair
Poor
N/A
Overall quality of course was:
The course content was:
The instructor's competence and effectiveness in teaching the subject matter was:
Course content and logistical organization was:
Rate how well the course environment promoted student engagement and expanded my EMS outlook:
Lead and Adjunct Instructor enthusiasm was:
Answers to student questions were:
Availability of extra help when needed was:
Use of class time was:
Amount you learned was:
Relevance of course content was:
Content matched reality of Field EMS:
Content matches directions currently provided by EMHIS:
I would recommend this course to a friend:
Intellectual challenge was:
This course will enhance my ability to provide sound patient care:
I feel this course made me a better clinician
Waste of time
1
2
3
4
Most Definitely
5
1 is Waste of time, 5 is Most Definitely
Is there any other feedback you'd like to give on this class?
Are there any specific topics you would like to have for future PDI?
Why did you rate any of the above categories as "poor"? Please elaborate.
Student Logbook
Sign IN Time (HH:MM)
*
Hour Minutes
Sign OUT Time (HH:MM)
*
Hour Minutes
Pay Status
*
Please Select
OTP
Detail
Volunteer
I attest that I attended this ALS PDI Class during the times I indicated in the above fields:
*
Submit!
Should be Empty: