Student Resource – Emergent Education LLC

Resources

Student Externship Form

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– Step 1 of 2

Preceptor Date I

Student Name *

First

Last

Student Level *

Preceptor Name *

First

Last

Preceptor Level *

Date / Time Beginning Shift *

Date

Time

Date / Time Ending Shift *

Date

Time

Clinical Site *

Total Clinical Hours *

Total Patient Contacts *

Total Patient Transports *

Patient Age/Sex/Complaint

Age *

Sex *

Complaint *

Skills

Skill P/A/O *

P/A/O *

Affective Domain

On a scale of one (1) to five (5), where one (1) is poor and five (5) is excellent, please rate yourself for each of the following:

Hygiene: *

Examples of professional behavior include, but are not limited to: Clothing is appropriate for clinical rotations, neat, clean, and well maintained; good personal hygiene and grooming.

Self Confidence: *

Demonstrating the ability to trust personal judgement; demonstrating an awareness of strengths and limitations; exercises good personal judgement; seeks learning opportunities in areas of weakness.

Time Management: *

Consistant punctuality; completing tasks, clinical documentation, and assignments on time, reporting to scheduled activities/clinicals consistently, takes corrective action promptly to correct deficits.

Team Diplomacy: *

Placing the success of the team above self-intrest; not undermining the team or team lead; helping and supporting other team members; showing respect for all team members; remaining flexible and open to change; communicating with others to resolve differences.

Psychomotor Skills: *

Student can thoroughly describe skills within his/her scope of practice and in relation to pace in course, and accomplishes proficiently and with little direction.

Shift Objectives: *

Student reviews objectives of the shift with preceptor and/or other shift leaders or crew members. The student takes a certain degree of ownership to be part of the team and goal assigned.

Clinical Site Rating *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Preceptor Rating *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Learning Experience Rating *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

I would like to speak to.. *

I would like to speak to the Program Director snd/or Clinical Director regarding this clinical site and /or Preceptor.

Signed *

Please type your full name to electronically sign this form.

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EMERGENT Acknowledgement Name

Name *

First

Last

Email *

Today's Date *

EMERGENT EDUCATION LLC ALS AND BLS PRECEPTOR TRAINING RESOURCE

ACKNOWLEDGEMENT PAGE I have received, reviewed and understand the Advanced Life Support Field Preceptor Training/Resource Manual, and I affirm that I am an authorized preceptor with my EMS Agency and EMS Physician.

Acknowledgement *

Signature *

Please input your full name as your affirmation of electronically signing this document.

Preceptor Evaluation Form

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– Step 1 of 4

Preceptor Name *

First

Last

Preceptor Level *

Email *

Student Name *

First

Last

Student Level *

Date / Time Beginning Shift *

Date

Time

Clinical Site *

Affective Domain

On a scale of one (1) to five (5), where one (1) is poor and five (5) is excellent, please rate yourself for each of the following:

Hygiene: *

Examples of professional behavior include, but are not limited to: Clothing is appropriate for clinical rotations, neat, clean, and well maintained; good personal hygiene and grooming.

Self Confidence: *

Demonstrating the ability to trust personal judgement; demonstrating an awareness of strengths and limitations; exercises good personal judgement; seeks learning opportunities in areas of weakness.

Time Management: *

Team Diplomacy: *

Psychomotor Skills: *

Student can thoroughly describe skills within his/her scope of practice and in relation to pace in course, and accomplishes proficiently and with little direction.

Shift Objectives: *

Student reviews objectives of the shift with preceptor and/or other shift leaders or crew members. The student takes a certain degree of ownership to be part of the team and goal assigned.

Student Overall Rating *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Program Rating *

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

Please list the student's strengths: *

Please list the student's weaknesses: *

What recommendations can you make to improve the program or your experience with the students? *

I would like to speak to.. *

I would like to speak to the Program Director snd/or Clinical Director regarding this student.

Phone *

Signed *

Please type your full name to electronically sign this form.

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This is a preview of your submission. It has not been submitted yet!
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Self the Overall