Sub-Section 3-490-72 - Paramedic Field Internship Mentor Approval Form

CMH EMS Education Manual

Part One (completed by the paramedic student)

Things to consider when selecting a mentor: Your preceptor should be someone who challenges you to do your best and is not afraid to tell you where you need to improve. Learning and improving should make you uncomfortable. So, pick someone that intimidates you. When you are done with field internship, you want to look back and be proud of your success. This is arguably the most important part of your paramedic education.

Mentor's name:
Mentor's email address:
Mentor's cell phone number:

All of the following must be true of your selected mentor:

The mentor listed above is the type of paramedic I want to be.
The mentor listed above has a work schedule that is sufficient to provide me with opportunities to accomplish the required number of ALS team lead calls.
The mentor listed above is NOT my friend or relative outside of work.
The mentor listed above has NOT been one of my regular partners at work.

Student's name:
Student's signature:
Date signed:

Part Two (completed by the mentor's clinical/education/quality officer)

Being a paramedic mentor is a serious commitment. Please help us ensure the highest quality of mentorship by completing this form.

Officer's name:
Officer's title:
Officer's email address:

Please mark your opinions below as they relate to the mentor listed above:

The mentor listed above is currently an FTO or preceptor for new hires in my organization.
The mentor listed above is clinically competent and is fully knowledgeable about our protocols.
The mentor listed above is a good employee and is fully knowledgeable about our policies and procedures.

Officer's signature:
Date signed:

Part Three (completed by the mentor)

Congratulations on being requested as a paramedic student mentor. The student has given you a significant compliment by indicating you are the type of paramedic they want to be. The goal of the field internship phase is to bridge the gap between the classroom and the practical parts of being a paramedic. Individual skills such as assessments, starting IVs, etc. should be adequate at this phase. Skills should not be the focus of field internship. There are vital skills that cannot be honed in the classroom that should be the focus of field internship: self-awareness, critical thinking, decision making, verbal communication, and self-confidence.

Please keep in mind that students need the opportunity to succeed or fail. Your job as mentor is to create space and time for the student to perform. Student actions may only be mediocre at this point and that is OK as long as crew or patient safety is not being compromised.

Please score the student's lowest performance. Rate the result, not the effort of the student. The student should be responsible for the call from the start to the end (including routing to the call, staff interaction, and documentation). Please allow and encourage the student to document the call in your ePCR software. You may delete the report and generate your own, append your comments to the bottom, and/or review and approve the report as is with your signature.

If you find that your student needs a lot of prompting, they are not ready for field internship. Have that conversation with the student and feel free to contact the lead instructor with your comments. It is absolutely OK to require more field experience time (ambulance ride-along where they are not team lead) before they continue to field internship.

Requirements of a mentor:

Preceptor education is required. If you have already completed education such as FTO, preceptor, or field instructor, please attach a copy of that certificate to this form. If not, you will be assigned an online preceptor education on the Platinum Planner website that will need to be completed before the student's mentorship starts.
Multiple forms will need to be completed to document the student's performance.

After each patient contact, the following form will need to be completed. http://ozarksems.com/eval-clinical-team-lead.php.
After each shift, the following form will need to be completed. http://ozarksems.com/eval-clinical.php.
After successfully completing field internship and being released to test at NREMT, the following form will need to be completed. http://ozarksems.com/eval-clinical-mentor-final.php.

Given all above, if you agree to be paramedic mentor to the student listed, please sign and date below.

Mentor's signature:
Date signed:

Feel free to contact the program director or lead instructor at any time. Thank you for your dedication to our profession.

Program Director: 417-597-3688, theron.becker@citizensmemorial.com
Lead Instructor: 573-220-8126, brice.flynn@citizensmemorial.com

Change Log:

Date	Link to previous version	Description of change
10/31/20		Moved online

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CMH EMS Education Manual is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Based on a work at http://ozarksems.com/edman-4-240.php.

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