2006-07 EMT-B Record Of Clinical Training
Name __________________________ Date_____________________
Hospital__________________________
Start Time_____________ Ending Time_________ Total Hours_____
Squad Comments
___________________ ____________________________________________________
___________________ ____________________________________________________
___________________ ____________________________________________________
___________________ ____________________________________________________
Total Number of Pt's Seen ____________
Total Number of Vitals Taken ____________
Total Histories Taken ____________
Student Evaluation
(Low) (High)
Ability and willingness to perform tasks assigned 1 2 3 4 5
Communication and rapport with patients 1 2 3 4 5
Ability to perform under stress 1 2 3 4 5
Attitude and professionalism 1 2 3 4 5
Cooperation and courtesy 1 2 3 4 5
Response to instructions and critique's 1 2 3 4 5
Overall performance 1 2 3 4 5
Student Strengths:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Areas to Work on:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Other Comments:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Signature of Evaluator:__________________________________________
Print Name of Evaluator__________________________________________
Note to Evaluator: If there were any problems or concerns that you would
like to bring up to the instructor, please let us know.