1

CSULB Emergency Medical Technician (EMT) Program

Hospital Clinical / Ambulance Ride-Along Form


Instructions: CSULB students complete the following Sections 1, 2, and 3 below and Section #5 on the
following page. Section #4 must be completed by hospital or ambulance preceptor.

Section #1
Student ID: Student Name:
Date: Time In: Time Out:
Hospital Name / Ambulance Company:

Section #2
Patient Gender Age Chief Complaint Pulse Resp. B/P Treatments
1 M F
2 M F
3 M F
4 M F
5 M F
6 M F
7 M F
8 M F
9 M F
10 M F

Section #3
EMT Skill Observed Assisted Performed Comments
Airway Adjuncts
Assisting ALS
CPR/FBAO
Oxygen
Patient Assessment
Patient Handling
Spinal Immobilization
Bandaging/Splinting
Vital Signs
Other:

Section #4 (To be completed by hospital or ambulance preceptor)
Nurse, Paramedic or EMT Preceptor Name (Please Print):
Did student meet uniform and equipment requirements? YES NO
Was student well groomed? YES NO
Was student professional and courteous? YES NO


___________________________________________ __________________
Hospital or Ambulance Preceptor Signature Date

2

Section #5

Instructions: Students must complete the following detailed report on one patient from the
previous page.

Patient Number: Age: Gender: Weight:
Location:
Level of Distress:
Chief Complaint:
Patients Position/Mechanism:
Level of Consciousness:

Focused History and Physical
O


S

P


A

Q


M

R


P

S


L

T


E


GCS Body Check Findings
Eye
Verbal
Motor

Vitals
B/P Lungs
Respirations Eyes
Skin Signs Pulse

Treatments