EMS Preceptor Productivity Report

All EMS Preceptors: Please use the following form to track all preceptor activities. Complete this form after each preceptor event.

Fields marked with >> are required.

Preceptor Information

Preceptor's Name>>

Preceptor's E-mail>>

Student Information

Student's Last Name>>

Student's First Name>>

Affiliation

If Other Affiliation

Please specify

Type of Student>>

Date Student was Precepted>>

Activity Hours>>

Topics Covered>>

Problems/Issues

Student Performance

Program Comments

Revised March 16, 2010