Als Field Internship Evaluation Objective 4 Form - Suffolk County Emt-Cc Training Program
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1Suffolk County
EMT-CC Training Program
ALS Field Internship Evaluation Objective 4
STUDENTS NAME:________________________________
DATE:____/______/______
PRECEPTORS NAME:______________________________
EMT #: ________________
ENROUTE TIME:________
DESTINATION TIME: ___________
TOTAL TIME: __________
TYPE OF CALL:_________________________(
).
e.g. Cardiac, Trauma, OB, Medical, Etc.
PCR # _______________________
Medical Control Operator # ___________________
EVALUATION
SKILL
RATING SCALE
COMMENTS
.
LEADERSHIP SKILLS:
1
2
3
4
5
1
a. Medical Knowledge / Protocol Knowledge
b. Ability to establish priorities & control scene
c. Functions without coaching or prompting
d. Functions as “Team Leader”
e. Functions calmly under stress and displays self-confidence
f. Delegates tasks appropriately using explicit directions
g. Formulates presumptive diagnosis
h. Implements appropriate treatment plan
i
Ability to oversee other providers
.
j. Other (Specify) _______________________
1
2
3
4
5
COMMENTS
2.
TEAMWORK SKILLS:
a. Functions as a ”Team Member” as well as “Team Leader”
b. Ability to establish priorities & control scene
c. Resolves conflicts tactfully
d. Performs quickly when situation necessitates
e. Interfaces well with on scene personnel
f. Works efficiently without wasted time / effort
g. Offers positive suggestions to crew
h. Other (Specify) _______________________
3.
INTERPERSONAL SKILLS:
COMMENTS
1
2
3
4
5
a. General attitude
b. Accepts responsibility and admits mistakes
c. Reacts positively to constructive criticism
d. Display good patient rapport
e. Shows empathy for patient condition
f. Treats all patients with equal concern
g. Controls anger / temper in difficult situations
h. Displays ability to handle stress / fatigue
i. Handles bystanders appropriately / effectively
j. Other (Specify)_______________________
COMMENTS
Optional: Please contact me about this evaluation. My name is ______________ . My phone # is _________________
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