Nys Emergency Medical Services Emt Clinical Evaluation Form Page 2
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3NYS EMERGENCY MEDICAL SERVICES EMT CLINICAL EVALUATION FORM
This form must be completed for each block of clinical rotation time the student attends
o
o
EMT-B Student Name:_____________________________________ Rotation Type:
ED Site
Ambulance
EMS Course Sponsor: _____________________________________ Course CIC: _______________________________________
CIC Contact Phone #: ____________________________________
Hospital/Agency Name: _____________________________________
Student Arrival Time:___________________
Departure Time:___________________
Date: _______________________
Rating Key:
1 = Needs improvement – Student did not meet the minimum standard of performance
2 = Satisfactory – Student met the minimum standard, but required guidance or assistance
3 = Very Good – Student performed the minimum standard without guidance or assistance
4 = Excellent – Student shows mastery level and was able to function independently
PLEASE USE THE BACK OF THIS FORM FOR ADDITIONAL COMMENTS IF NEEDED
ED or Ambulance
Amt. of times
Overall
Skill Performed
Performed
Rating
Preceptor’s Comments / Recommendations for Student Improvement
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Parent category: Education