Employee Evaluation
Date
Shift:
A B C D
Employee
Level
EMT EMT-I EMT-P
Time In:
Time Out:
Evaluator Name
Level
EMT EMT-I EMT-P
# of BLS Calls Ran
# of ALS Calls Ran
Employee Performance

(1= not performed, 2=unacceptable, 3=needs improvement, 4=acceptable, 5=exceeds expectations)
 
1
2
3
4
5
Initial contact with the patient
Patient Assessment
Completes medical history
Performs skills in a timely manor
Treats patient per protocol
Physcological support to the patient
Relay of patient information on radio
Communication with hospital staff
Performs BLS skills
Performs ALS skills
Preperation of unit before/after calls
Driving of EMS Unit
Knowledge of equipment/supplies
Ability to document patient care reports

Skill Performance

(1= not performed, 2=unacceptable, 3=needs improvement, 4=acceptable, 5=exceeds expectations)
 
1
2
3
4
5
12 Lead
Airway-ET Confirmation
Airway-Intubation (oral)
Airway-Intubation (nasal)
Airway-Oral Airway
Airway-Suction
Blood Glucose Anaylsis
Cardiac Monitoring
Capnometry
Cardioversion
Chest Decompression
Combitube
Cricothyrotomy
CPR
Defibrillation
External Pacing
Injection-IM
Injection-SQ
IV Access
Medication Administered
Any item checked 1, 2 or 3 should be documented in the general comments section.

General Comments

Employees address being evaluated 
Form being submitted by:
By submitting this form, I am stating that all statements are true and correct as I have observed them on this date.