EMT FTO Evaluation Form
Division
*
Monte 911
North
South
West/Sullivan
EMT Preceptee Name
*
First Name
Last Name
Shield Number
Driving Status
*
No Restrictions
Restricted For Infractions
Restrictions Due to 30 Days
FTO/Evaluator
*
First Name
Last Name
Shield Number
Unit
*
Date
*
/
Month
/
Day
Year
Date Picker Icon
ALS Transports
911 - BLS Txp
911 - ALS Txp
BLS Transports
911 - RMA
Call Types
*
Rows
IFT
911 txp
911 RMA
BLS
ALS
Total IFT
Total 911
Total Calls
Total Transports
Total 911s
Total Calls
Assessment
*
Rows
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 - ALS
911 - BLS
RMA
Transfer - ALS
Transfer - BLS
Call Type
*
Skills Performed
*
None
AED
Airway Mgt
ALS Interface
Bleeding Control
C – Spine
Car Seat
Code 50
CPR
Glucometry
Hospital Note
Meds – ASA
Meds – Epi
Meds – Glucose
Meds – Narcan
Reeves
Splinting
Stair Chair
Stretcher
Turn Over Report
Other
Describe Call and Performance
*
Run Number or Address
*
Priority
*
911 - ALS
911 - BLS
RMA
Transfer - ALS
Transfer - BLS
Call Type
*
Skills Performed
*
None
AED
Airway Mgt
ALS Interface
Bleeding Control
C – Spine
Car Seat
Code 50
CPR
Glucometry
Hospital Note
Meds – ASA
Meds – Epi
Meds – Glucose
Meds – Narcan
Reeves
Splinting
Stair Chair
Stretcher
Turn Over Report
Other
Describe Call and Performance
*
Run Number or Address
*
Priority
*
911 - ALS
911 - BLS
RMA
Transfer - ALS
Transfer - BLS
Call Type
*
Skills Performed
*
None
AED
Airway Mgt
ALS Interface
Bleeding Control
C – Spine
Car Seat
Code 50
CPR
Glucometry
Hospital Note
Meds – ASA
Meds – Epi
Meds – Glucose
Meds – Narcan
Reeves
Splinting
Stair Chair
Stretcher
Turn Over Report
Other
Describe Call and Performance
*
Overall Performance
*
Pertinent Notes on EMT
*
Reviewed Evaluation with EMT
*
Yes
No
EMT E-Mail Address (This report will be shared with the Trainee)
*
example@example.com
Driving Clearance
*
Not Applicable
Cleared to Drive
Driver Restricted
Needs Further Remediation
Details Involved In Driver Clearance Recommendation
*
Follow Up
*
Request Follow Up with QA
Request Follow Up with Supervisor
None
FTO Signature
Save
Submit
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