Paramedic Student Mentor Final Approval

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for being a mentor for a CMH EMS paramedic student. Please use this form as the final approval documentation for your student.

Link to this form: http://ozarksems.com/eval-clinical-mentor-final.php

Mentor name: *

Student name: *

By checking "Yes" below, I acknowledge this student has completed his or her field internship requirements to the best of my knowledge. *

Yes

By checking "Yes" below, I acknowledge this student has demonstrated basic, entry-level knowledge, skills, and abilities to become a paramedic. *

Yes

By checking "Yes" below, I indicate that I would be comfortable with this student taking care of my family if they were having a medical emergency. *

Yes

All questions above must be answered "Yes" to be able to answer "Yes" on the following question.

By checking "Yes" below, I recommend passing this student and allowing him or her to test for state and national registry paramedic licensure. *

Yes

If you marked "No" on any of the questions above, please document what, specifically, they must do to improve.

For more information or comments, please feel free to contact the CMH EMS Education Director.

Theron Becker (theron.becker@citizensmemorial.com) 417-597-6488

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms