Clinical agreement preceptor orientation

Clinical Agreement
WHEREAS it is purposed that the Department of Allied
Health Careers is organized for the purpose of providing an
educational program to train Emergency Medical students,
and/or any subdivision of the EMS Curriculum.
WHEREAS the Cooperating Fire Department is willing to
provide facilities to enable the Training Division to meet
this objective, and also provide clinical experiences upon
terms and conditions set forth in this agreement.

Clinical Agreement
WHEREAS the Cooperating Fire Department and the
school mutually desire to promote excellence in the
provision of professional services, health education and
research, and to contribute to the professional growth and
competence of students in educational programs..

Clinical Agreement
In consideration of the foregoing premises and the
mutual agreements and conditions set forth in the
agreements set forth in the agreement, the parties agree as
follows:
Clinical Experience
Supervision
Student Assignment
Records
Legal Status

Clinical Agreement
Clinical Experience The school shall plan and administer
the Program to satisfy the requirements of all applicable
laws, regulations and licensing or supervisory agencies.
Department shall provide the appropriate use of its
facilities by students participating in the Program, along
with an orientation at the beginning of each new training
session. (any departmental orientation required by your AHJ)

Clinical Agreement
Supervision The School shall supervise all students
enrolled in the Program in accordance with the pertinent
laws.
During clinical educational experiences, the students shall
be permitted to participate in the professional services at
the Department under the supervision of the appropriate
professional staff of the Department and the School.

Clinical Agreement
The scope of the students’ participation will be
determined by the applicable Department policies and to
the extent permitted by law.
The Department specifically agrees that students will
work on Department vehicles as an extra (or 3rd) person
only and shall be supervised by a designated preceptor who
is an experienced certified provider and has completed the
Schools preceptor orientation training.

Clinical Agreement
Student Assignment The School shall assign such students
to the Department, as the parties mutually agree.
Students shall have ID badges provided by the School and
shall wear the designated School uniform. The students
shall comply with the policies, procedures, and rules and
regulations of the Department at all times.

Clinical Agreement
The Department shall have the right to request the
removal of any student from the program for cause upon
written notification to the School, such information shall
set forth the basis for the request. The School shall comply
immediately with the request for the removal.
Disciplinary proceedings against students shall be
conducted by the School in accordance with its policies and
procedures.

Clinical Agreement
All School faculty and students shall document
appropriate training concerning applicable OSHA
requirements, including without limitation, blood borne
pathogens, and shall have received such immunizations as
the Department requires of its faculty and students prior to
being assigned to the Department.

Clinical Agreement
Records The School shall maintain all educational records
and reports relating to the clinical education program
completed by the students at the Department.
The Department shall have custody and control of all
medical records and charts contained in patient files and
neither the School nor the students may remove or copy
such records except pursuant to a specific request in writing
with respect to and from a patient or his/her legal
representative, or patients to whom such records pertain or
with written permission of the Department.

Clinical Agreement
Identity of patient, the nature of the procedures or
services provided to patients and information included in
the patients’ medical records shall be confidential and shall
not disclosed by the students other than for use in direct
patient care by authorized personnel during the current or
future Department treatments

Clinical Agreement
Legal Status It is understood and agreed that the students
are enrolled in a professional education program offered by
the School.
It is also understood and agreed that the students may
participate in clinical educational experiences at the
Department under appropriate supervision by the School
and the Department.

Clinical Agreement
Except for those students currently but separately
employed by the Department, the students shall not be
deemed or considered to be employees of the Department
for any purposes as a result of their participation in the
Program and shall remain at all times students of the
school.
Nothing in this Agreement is intended or shall be deemed
or construed to create any relationship between the parties
other than that of education affiliation.

Clinical Agreement
The Department shall not be liable for any claim, injury,
demand or judgment arising out of any action or failure to
act by the School, its agents, employees or students and the
School herby agrees to indemnify and hold the Department
harmless from any cost and expenses
Nondiscrimination Clause No student shall, on the
grounds of race, color, sex, creed, age or national origin be
excluded from participation in , be denied the benefits of,
or be subject to discrimination under any provision of this
agreement

Dress Code
Clinical Uniforms
Students and Clinical Instructors while engaged in the
clinical setting will be required to follow the above
guidelines including the following:
• Wear the school approved uniform shirt displaying
student or preceptor status
• Wear the assigned ID badge indicating student or
preceptor status
• Must wear black or blue uniform pants, casual dress
pants or slacks. No shorts or jeans are permitted.
• Black shoes or duty boots. No open toe shoes are
permitted

Admission Policy
Admission Policy
No student will not be permitted to start any class without
a complete application on file, including all signatures from
his or her agency. The application consists of:
• Demographics form
• Waiver and Release
• Copy of any prerequisites such as copy of EMT certification to take an Advanced
Emergency Medical Technician course or higher. Certification will be verified before
class approval.
• Copy of NIMS 100 and 700 which can be found at www.training.fema.gov.
• Student Medical Requirements form demonstrating the following requirements are
met:
Copy of TB test within 1 year
Hepatitis B vaccine or signed refusal waiver
Rubella immunization and titer if needed
Copy of a recent physical within 1 year
Signed form of relative knowledge of universal precautions

Preceptor
Clinical Preceptor
Clinical Preceptors are defined and function under the
Newton Township Training Division’s Policy and Procedures.
All Preceptors must complete the Clinical Preceptor
Orientation and have a signed waiver of acknowledgment
of their duties prior to evaluating any student activity.
All signatures obtained from a Clinical Preceptor must be
signed in red ink only.

Preceptor
The Newton Township has two Clinical Preceptor roles
defined below:
Hospital Clinical Preceptors must be under contract and
approved by the Training Coordinator and EMS Advisory
Committee and maintain their current certification status
and at least an EMS CEU or AEI certification.
Clinical Preceptor can only supervise students at or below
their respective level of certification.

Preceptor
Hospital Clinical Preceptors are also subject to the same
requirements as the students regarding vaccinations or
Healthcare requirements required by the Hospital Clinical
Affiliation under contract with the Newton Township
Training Division.

Preceptor
Field Clinical Preceptors
Only Employees/Volunteers of Departments or EMS
agencies that have an Affiliation Agreement on file with the
Newton Township Training Division are permitted to serve
in the role of Field Clinical Preceptor.
Field Clinical Preceptors can only supervise students at or
below their respective level of certification.

Clinical Requirements
Student Clinical Requirements
Student will not be permitted to begin any clinical time
until after all set forth requirements have been met with
the class and clinical location. Students must abide by the
clinical uniform outlined above and their own stethoscope.
Students must also bring their clinical logbook which will
include the following:
 Student Handbook
 Student and Preceptor Evaluations
 Student Clinical Hours Sheet
 BLS Skills sheet, to indicate what activities the student
performed during clinical
 Blank EMS reports (10)

Students in the EMT course must complete 8 hours of
hospital internship under the direction of a contracted
Preceptor.
Students are only allowed to perform assessments and
function only in an observatory role in the hospital setting.

Students in the EMT course must complete 10 hours of
documented field clinical time with Employees/Volunteers
of Departments or EMS agencies that have an Affiliation
Agreement on file.
A list of these Department or Agencies will be provided to
each student along with their contact numbers and
locations. Field clinical time is only permitted when the
Department or EMS agency staffing is at least two certified
EMT’s or an EMT and AEMT/Paramedic is staffed on the
unit.

AT NO TIME IS THE EMT STUDENT ALLOWED TO BE
COUNTED AS PART OF THE CREW or BE COUNTED AS PART
OF THE DEPARTMENTS/AGENCIES STAFFING DURING
CLINICALS.

Clinical Logbook
EMS Run Sheet (yellow paper)
To be used to document
Clinical Assessments in the
Students own handwriting
And signed by the preceptor

Clinical Logbook
EMS Clinical Hours (orange paper)
Students are required to complete 18 hours of clinicals.
(8 hours) at Genesis
Healthcare.
(10 hours) completed at Departments or EMS contracted
agencies with a field
clinical preceptor.
Newton Township Training Division
H on or - Pr i de - D edi cat i on
5490 Maysville Pike Box 181
White Cottage, OH 43791-0181
Phone: 740/849-2418 EMERGENCY 911 Fax 740/849-2324
EMS Clinical Hours
Student Name: ________________________________ Course Number: ________________________
Lead Instructor: _______________________________ Certification Number: ___________________
Course Starting Date: __________________________ Course Ending Date: ____________________
Date Time in Time Out Preceptor Name Preceptor Signature Location or Site Name No. of Calls Reports
Students are required to complete 18 hours of clinicals. (8 hours) at Genesis Healthcare Hospital Emergency
Department with a clinical preceptor. (10 hours) completed at Departments or EMS contracted agencies with a field
clinical preceptor.

Clinical Logbook
Student Evaluation (hot pink)
Preceptors are required to fill out an evaluation on each
student at the end if their clinical period.
EMS Student Evaluation
Preceptor Name Location or Site Name Date Time In Time Out No. of Hours
Please evaluate the student using a 0-5 scale for each of the following.
(5=Field Competent, 4=Appropriately Uses Skills, 3=Satisfactory, 2=Some Coaching Needed, 1=Needs Improvement or Not Competent, 0=Dangerous to Practice)
Integrity-Consistent honesty; being able to be trusted with the property of others; can be trusted with confidential information; complete and accurate
documentation of patient care and learning activities
Empathy-Shows compassion towards others; responding appropriately to emotion response of patients and family; demonstrates respect for others;
demonstrates and calm and compassionate demeanor towards those in need; is supportive and reassuring to others.
Self-Motivation-Takes initiative to complete assignments and improving and/or correct behavior; is able to follow through with task without constant
supervision; consistently striving for excellence in all aspects of patient care; takes advantage of learning activities
Appearance and Personal Hygiene-Clothing and uniform are neat, clean, and well maintained; good personal hygiene and grooming
Self-Confidence-Demonstrates the ability to exercise good personal judgment; demonstrates an awareness of strengths and limitations
Communications-Speaks clearly; writes legibly; listens actively; adjust communication strategies to various situations and audiences
Time Management-Consistent punctuality; completes task and assignments on time
Teamwork and Diplomacy- Places the success of the team above self-interest; not undermining the team; helps and shows respect for all
Respect-Being polite to others; not using derogatory or demeaning terms; behavior in a manner that brings credit to the profession
Patient Advocacy-Does not allow personal bias or feelings to interfere with patient care; places the needs of the patient above self interest
Careful Delivery of Service-Mastering and refreshing skills; performing complete equipment checks; demonstrates careful and safe
ambulance operations; familiar with equipment on hand; follows procedures and protocols; follows orders
Preceptor Comments:
Student Comments:
Preceptor Signature___________________________ Student Signature______________________________

Clinical Logbook
Preceptor Evaluation (Lime Green)
Students are required to fill out an evaluation on each
Preceptor at the end if their clinical period.
EMS Preceptor Evaluation
Preceptor Name Location or Site Name Date Time In Time Out No. of Hours
Please evaluate the student using a 0-5 scale for each of the following.
(5=Field Competent, 4=Appropriately Uses Skills, 3=Satisfactory, 2=Some Coaching Needed, 1=Needs Improvement or Not Competent, 0=Dangerous to Practice)
Integrity-Consistent honesty; being able to be trusted with the property of others; can be trusted with confidential information; complete and accurate
documentation of patient care and learning activities
Empathy-Shows compassion towards others; responding appropriately to emotion response of patients and family; demonstrates respect for others;
demonstrates and calm and compassionate demeanor towards those in need; is supportive and reassuring to others.
Self-Motivation-Takes initiative to complete assignments and improving and/or correct behavior; is able to follow through with task without constant
supervision; consistently striving for excellence in all aspects of patient care; takes advantage of learning activities
Appearance and Personal Hygiene-Clothing and uniform are neat, clean, and well maintained; good personal hygiene and grooming
Self-Confidence-Demonstrates the ability to exercise good personal judgment; demonstrates an awareness of strengths and limitations
Communications-Speaks clearly; writes legibly; listens actively; adjust communication strategies to various situations and audiences
Time Management-Consistent punctuality; completes task and assignments on time
Teamwork and Diplomacy- Places the success of the team above self-interest; not undermining the team; helps and shows respect for all
Respect-Being polite to others; not using derogatory or demeaning terms; behavior in a manner that brings credit to the profession
Patient Advocacy-Does not allow personal bias or feelings to interfere with patient care; places the needs of the patient above self interest
Careful Delivery of Service-Mastering and refreshing skills; performing complete equipment checks; demonstrates careful and safe
ambulance operations; familiar with equipment on hand; follows procedures and protocols; follows orders
Preceptor Comments:
Student Comments:
Student Signature___________________________ Training Coordinator Signature______________________________

Clinical Logbook
BLS Skills Sheet (White)
Students are required to fill out a description of any skills
they performed during clinical activities. These skills can
include:
Vitals
Splinting
Immobilization
Airway
CPR
Ect.
EMS Clinical Sheet BLS Skills Performed
Date Location or Site Name Preceptor Name Description of Skills Preceptor Signature
Students are required to document any skills including assessments performed during clinicals

Student Handbook
Student Handbook
Additional policies and procedures are covered in the
Student Handbook which is it be with the student during
clinicals.
The Training Coordinator has the final say in resolving any
conflicts between this document and the Training Division
Policy and Procedures.

 Be the example
 Demand only the best from the student
 Respect our motto: Honor, Pride, and
Dedication
 Respect the customer and public we serve

Training Division
The time you have with students is valuable. This may be
your only chance to effect that persons career.
The new generation needs us
Its not about you or your credentials. It’s about our
students getting the full potential of each one of us.
If you have any questions feel free to call at any time
OR
Captain Josh Bryan, Training Coordinator
newtontownshiptrainingdivision@gmail.com
(740) 819-3622
Erika Wickham, Clinical Coordinator
(740) 683-6408

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