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DocuSign Envelope ID:79C5D167-B6CA-4E59-B4AC-AA38CC1 B20BD <br /> Part 2: <br /> The trainee is recommended for extended field shifts due to the following factor(s): <br /> Inability to consistently perform patient care skills <br /> Inability to demonstrate capability in all competency areas <br /> Inability to demonstrate adequate communication skills <br /> Inability to independently complete adequate PCRs <br /> Inability to demonstrate assertiveness/proactive behavior <br /> Inadequate number of patient contacts <br /> Inadequate coverage of competencies during precepting shifts <br /> Other <br /> Areas needing further development and plans for improvement are indicated on the attached Period <br /> Progress Report. <br /> Number of additional shifts recommended: <br /> Preceptor Signature: Trainee Signature: <br /> Date: Date: <br /> 1525 Signature: Supervisor Signature: <br /> Date: Date: <br /> Training Officer: Medical Director: <br /> Date: Date: <br /> For Training Officer use <br /> #of Shifts Drug Test Medical Boards Protocol Test <br /> #of Skills Check off Precepting Sheets 12 Lead test <br /> Patients <br /> SOG Test Sim-Lab Map Test <br /> 30 <br />