Instructor Evaluation Form

*CoAEMSP Program Number:

*Program Sponsor:

*Clinical/Field Site:

*Date Visited:

*Coordinator/Adjunct Name:

*Unit(s) Visited:

*Individuals Visited:

1: Unacceptable   2: Needs Improvement   3: Acceptable   4: Proficient

*Was the student in proper uniform?

N/A    1    2    3    4   

*Was the student actively engaging with staff?

N/A    1    2    3    4   

*Does the student receive constructive criticism?

N/A    1    2    3    4   

*What areas does the student need improvement on?