EMS Daily Clinical Internship Evaluation

Preceptor Information

Preceptor Name(Required)

First Last

Preceptor Email(Required)

Student Information

Student Name(Required)

Date(Required)

Student Arrival Time(Required)

Student Departure Time(Required)

Grading Scale

4 = Exceptional (performed above expectations and course knowledge)
3 = Appropriate for experience level (functioning at the expected level in the program)
2 = Need moderate improvement (needs further education and practice to improve)
1 = Need significant improvement (needs intensive assistance and education to improve)

Student Performance

Learner Characteristics(Required)

Actively looked for learning experiences, participated with patient care, practiced required skills, sought advice to improve skills

Professionalism/Attitude(Required)

Arrived on time, appropriate appearance & hygiene, demonstrated professional behavior

Communication Skills(Required)

Patient assessments performed and reported completely and proficiently, interacted with patients and other health care professionals on a “student role” at an appropriate level.

Ethics and values(Required)

Respected patients, bystanders, the organization and other allied professionals; demonstrated compassion and empathy toward patients and others.

Daily Affective Aptitude Evaluation

Phase/Shift Objectives(Required)

The student reviewed current objectives and performed the tasks to the standards outlined. He or she requested and accepted constructive criticism and took personal responsibility for self-improvement.

Psychomotor Skills(Required)

The student was able to thoroughly describe all elements of applicable procedures and could accomplish psychomotor skills independently and proficiently.

Interview(Required)

The student completed comprehensive patient/bystander interviews. He or she demonstrated active listening.

Exam(Required)

The student completed an appropriate physical exam.

Treatment(Required)

The student formulated a field impression and implemented a treatment plan. Interventions performed were complete, satisfactory, and timely.

Remediation needed:

Area requiring immediate attention:

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