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| 2005/2006 Paramedic
Program |
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FIELD INTERNSHIP EVALUATION FORM |
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STUDENT |
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DATE |
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| SERVICE |
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PRECEPTOR: |
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# HOURS: |
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RUN#_______________ |
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| SKILLS PREFORMED |
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IV |
(A) |
ET |
(A) |
EKG |
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MED |
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(S) |
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(S) |
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CLINICAL IMPRESSION |
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| PRECEPTOR COMMENTS: |
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RUN#_______________ |
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| SKILLS PREFORMED |
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IV |
(A) |
ET |
(A) |
EKG |
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MED |
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(S) |
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(S) |
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CLINICAL IMPRESSION |
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| PRECEPTOR COMMENTS: |
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RUN#_______________ |
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| SKILLS PREFORMED |
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IV |
(A) |
ET |
(A) |
EKG |
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MED |
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(S) |
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(S) |
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CLINICAL IMPRESSION |
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| PRECEPTOR COMMENTS: |
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| 2005/2006 Paramedic
Program |
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FIELD INTERNSHIP EVALUATION FORM |
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| OVERALL SHIFT COMMENTS: |
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| Preceptor |
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| Preceptor Name
(print) |
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| Preceptor signature |
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| Student Signature |
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