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
# 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
Phychological 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.