EMT Field Performance Question Title * 1. Student's Name OK Question Title * 2. Preceptor's Name and Certification Level OK Question Title * 3. EMS Agency Bainbridge Island Fire Department Bremerton Fire Department Central Kitsap Fire & Rescue North Kitsap Fire & Rescue Olympic / Bremerton Ambulance Poulsbo Fire Department South Kitsap Fire & Rescue Other (please specify) OK Question Title * 4. Date of call Date / Time OK Question Title * 5. How is the student's ability in SCENE ASSESSMENT? Proficient Developing Needs Improvement Add Comment (optional) OK Question Title * 6. Did the student perform an adequate PATIENT ASSESSMENT? Yes, the student performed an PROFICIENT patient assessment. Yes, but is in the process of DEVELOPING this skill. No, the student only observed this skill. I did not observe this student performing this skill. Add Comment (Optional) OK Question Title * 7. Did the student obtain an appropriate PATIENT HISTORY? Yes, the student performed and APPROPRIATE patient history. The student is still DEVELOPING this skill. No, the student did not perform an appropriate patient history. (Please comment below) I did not observe the student performing a patient history. Comments: OK Question Title * 8. Did the student perform an ACCURATE set of vital signs. Yes, the student performed vital signs ACCURATELY. The student is still DEVELOPING this skill. No, the student did not perform accurate vital signs. (Please comment below) I did not observe the student performing a patient history. Comments: OK Question Title * 9. How would you rate the student on TEAM EFFORT? Did not perform as expected. Appeared too unsure of his/her self. Is developing EMS team skills. Expresses effort to be part of the team. Is able to perform some or all leadership skill. Did not perform as expected. Appeared too unsure of his/her self. Is developing EMS team skills. Expresses effort to be part of the team. Is able to perform some or all leadership skill. OK Question Title * 10. How would you rate the student on PATIENT INTERACTION? Did not perform as expected. Appeared too unsure of his/her self Is developing patient interaction skills. Performs as expected. Did not perform as expected. Appeared too unsure of his/her self Is developing patient interaction skills. Performs as expected. OK Question Title * 11. How would you rate the student in their ability to IDENTIFY PATIENT PRIORITIES? Did not adequately identify patient priorities. Is developing this skill. Performed patient priorities as expected. Performed better than expected in identifying patient priorities. Did not adequately identify patient priorities. Is developing this skill. Performed patient priorities as expected. Performed better than expected in identifying patient priorities. OK Question Title * 12. Rate the student on maintaining his/her composure during the call. Was NOT composed. Was VERY composed Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 13. How was the student's OVERALL PERFORMANCE on this call? Performed poorly. Is developing skills appropriately. Perform above expectations. Clear i We adjusted the number you entered based on the slider’s scale. OK Question Title * 14. Please add any further comments. OK DONE