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 <br /> <br />30|Page <br /> <br /> <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 /> <br /> Inability to demonstrate capability in all competency areas <br /> <br /> Inability to demonstrate adequate communication skills <br /> <br /> Inability to independently complete adequate PCRs <br /> <br /> Inability to demonstrate assertiveness/proactive behavior <br /> <br /> Inadequate number of patient contacts <br /> <br /> Inadequate coverage of competencies during precepting shifts <br /> <br /> Other <br /> <br />Areas needing further development and plans for improvement are indicated on the attached Period <br />Progress Report. <br /> <br />Number of additional shifts recommended: <br /> <br /> <br /> <br />Preceptor Signature: <br /> <br />Date: <br />Trainee Signature: <br /> <br />Date: <br />1525 Signature: <br /> <br />Date: <br />Supervisor Signature: <br /> <br />Date: <br />Training Officer: <br /> <br />Date: <br />Medical Director: <br /> <br />Date: <br /> <br /> <br /> <br /> <br /> <br /> <br />ForTrainingOfficeruse <br /># of Shifts Drug Test Medical Boards Protocol Test <br />#of <br />Patients <br /> <br />Skills Check off  <br />Precepting Sheets <br /> <br />12 Lead test <br />SOG Test Sim-Lab Map Test <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />DocuSign Envelope ID: 79C5D167-B6CA-4E59-B4AC-AA38CC1B20BD