EMT FTO Evaluation Form

EMT FTO Evaluation Form
Division*

Monte 911NorthSouthWest/Sullivan
EMT Preceptee Name*

First NameLast NameShield Number
Driving Status*
FTO/Evaluator*

First NameLast NameShield Number
Unit*
Date*

MonthDayYear
ALS Transports
911 - BLS Txp
911 - ALS Txp
BLS Transports
911 - RMA

Call Types*

	IFT	911 txp	911 RMA
BLS
ALS

Total IFT
Total 911
Total Calls
Total Transports
Total 911s
Total Calls

Assessment*

	Exceeds Expectation	Competent	Needs Improvement	Needs Remediation	Not Observed
Communication - Dispatch
Communication - Facilities
Communication - Family / Bystanders
Communication - FD / PD
Communication - Partner
Completion of PCRs
Continues Evaluation En-Route
Delegation
Destination Choice
Driving – Code 1
Driving – Code 3
Driving – With Patient on Board
End of Tour Duties Completed
Familiarity with Equipment
Form Compliance (Part 800, Repair Request, Incident Report, etc.)
Forms Appropriate Initial Impression
Identifies Appropriate Working Diagnosis
Lifting - Stretcher
Lifting - Reeves / Scoop
Lifting - Stair Chair
Part 800 Complete
Patient Assessment
Patient Packaging
PCR – Demographics Complete
PCR – Interventions Documented Appropriately
PCR – Narrative Appropriate
PCR – Patient History Complete
PCR - Signatures Complete
Professionalism
Protocols – Knowledgeable
Protocols – On - Line Medical Control Orders
Protocols – Operates Under Correct Protocol
Protocols – Standing Orders
Scene Management
Vital Signs – Blood Pressure
Vital Signs – Heart Rate
Vital Signs – Lung Sounds
Vital Signs – Skin CTC

Elaborate on Any Items Marked Needs Improvement / Needs Remediation*
Detail Steps Advised Employee For Remediation*
Call Information
Run Number or Address*
Priority*

911 - ALS911 - BLSRMATransfer - ALSTransfer - BLS
Call Type*
Skills Performed*

NoneAEDAirway MgtALS InterfaceBleeding ControlC – SpineCar SeatCode 50CPRGlucometryHospital NoteMeds – ASAMeds – EpiMeds – GlucoseMeds – NarcanReevesSplintingStair ChairStretcherTurn Over ReportOther
Describe Call and Performance*
Run Number or Address*
Priority*

911 - ALS911 - BLSRMATransfer - ALSTransfer - BLS
Call Type*
Skills Performed*

NoneAEDAirway MgtALS InterfaceBleeding ControlC – SpineCar SeatCode 50CPRGlucometryHospital NoteMeds – ASAMeds – EpiMeds – GlucoseMeds – NarcanReevesSplintingStair ChairStretcherTurn Over ReportOther
Describe Call and Performance*
Run Number or Address*
Priority*

911 - ALS911 - BLSRMATransfer - ALSTransfer - BLS
Call Type*
Skills Performed*

NoneAEDAirway MgtALS InterfaceBleeding ControlC – SpineCar SeatCode 50CPRGlucometryHospital NoteMeds – ASAMeds – EpiMeds – GlucoseMeds – NarcanReevesSplintingStair ChairStretcherTurn Over ReportOther
Describe Call and Performance*
Overall Performance*
Pertinent Notes on EMT*
Reviewed Evaluation with EMT*

YesNo
EMT E-Mail Address (This report will be shared with the Trainee)*
example@example.com
Driving Clearance*
Details Involved In Driver Clearance Recommendation*
Follow Up*

Request Follow Up with QARequest Follow Up with SupervisorNone
FTO Signature

Clear
Should be Empty: