SMS Inc, Preceptor Evaluation  EMT Basic Student
Each clinical student must have an evaluration completed per clinical shift.
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Email *
Student Name: *
Date *
Time in *
Time Out *
Preceptor Name and Title *
Total Shift Hours *
Part A Affecitve Domain/ Professional Appearance: *
Part A: Affective Domain /Preparedness : The student arrived ontime with appropriate eqiuptment.. pen, tablet of paper stethescope, eye protection,pen light, *
Initiative; Student demonstate interest in EMS through actions and interactions with Preceptor *
Conduct: Student interacts with patients, families & EMS Staff in a respectful and empathetic manner. Demonstrates respectabilty and professional ethics *
 Part B Psycomotor Domain/Careful Delivery of Service: Student follows plicies , procedures & Protocols. Uses appropriate safeguards in teh performance of duties. *
Part C: Cognative Domain/ Kowledge: the student can recall common terms, facts, principles and basic concepts in EMS *
Problem Solving: the student uses knowledge to solve a previously unencountered situation *
Evaluation : the student can judge the appropriatness of actions and can defend his / her decisions. *
Please use the space below to write any additonal comments and suggestions for further development of the students potential. *
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