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Student Externship Form
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Step
1
of 2
Student Name
*
First
Last
Student Level
*
— Select Choice —
EMT Student
Advanced EMT Student
EMT Student
Preceptor Name
*
First
Last
Preceptor Level
*
— Select Choice —
EMT
Advanced EMT
Paramedic
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
*
— Select Choice —
Male
Female
Unknown
Complaint
*
Skills
Skill P/A/O
*
P/A/O
*
— Select Choice —
Preformed
Assist
Observed
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:
*
— Select Choice —
1
2
3
4
5
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:
*
— Select Choice —
1
2
3
4
5
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:
*
— Select Choice —
1
2
3
4
5
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:
*
— Select Choice —
1
2
3
4
5
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:
*
— Select Choice —
1
2
3
4
5
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:
*
— Select Choice —
1
2
3
4
5
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 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 5 out of 5
Preceptor Rating
*
Rate 1 out of 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 5 out of 5
Learning Experience Rating
*
Rate 1 out of 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 5 out of 5
I would like to speak to..
*
— Select Choice —
Yes
No
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.
Preceptor Total Clinical
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Name
*
First
Last
Email
*
Name TRAINING 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
*
— Select Choice —
I agree
I do not agree
Signature
*
Please input your full name as your affirmation of electronically signing this document.
Submit
Preceptor Evaluation Form
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–
Step
1
of 4
Preceptor Name
*
First
Last
Preceptor Level
*
— Select Choice —
EMT
Advanced EMT
Paramedic
Email
*
Student Name
*
First
Last
Student Level
*
— Select Choice —
EMT Student
Advanced EMT Student
EMT Student
Date / Time Beginning Shift
*
Date
Time
Clinical Site
*
Next
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:
*
— Select Choice —
1
2
3
4
5
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:
*
— Select Choice —
1
2
3
4
5
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:
*
— Select Choice —
1
2
3
4
5
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:
*
— Select Choice —
1
2
3
4
5
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:
*
— Select Choice —
1
2
3
4
5
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:
*
— Select Choice —
1
2
3
4
5
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.
Next
Psychomotor Overall list
Student Overall Rating
*
Rate 1 out of 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 5 out of 5
Program Rating
*
Rate 1 out of 5
Rate 2 out of 5
Rate 3 out of 5
Rate 4 out of 5
Rate 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..
*
— Select Choice —
Yes
No
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.
Previous
Next
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