Daily
Observation
Report
Date
*
/
Month
/
Day
Year
Date
Name
First Name
Last Name
Start of Shift
*
1
2
3
4
5
Preparedness
1
2
3
4
5
Pass-on/Shift Handoff Report
6
7
8
9
10
Unit/Equipment Check
11
12
13
14
15
Driving pre-trip inspection
16
17
18
19
20
Equipment Operations
*
1
2
3
4
5
Medical Durable Goods
21
22
23
24
25
Gurney Operations
26
27
28
29
30
Radio
31
32
33
34
35
Driving
*
1
2
3
4
5
Mapping
36
37
38
39
40
Driving Ability
41
42
43
44
45
Backing
46
47
48
49
50
Vehicle placement and Exit Routes
51
52
53
54
55
Smooth Transport
56
57
58
59
60
EMS Skills and Knowledge
*
1
2
3
4
5
Protocol Knowledge
61
62
63
64
65
Policy and Procedure Knowledge
66
67
68
69
70
Interventions/procedures
71
72
73
74
75
Patient Care
*
1
2
3
4
5
Scene Safety/Awareness
76
77
78
79
80
Patient Interaction and Care
81
82
83
84
85
Patient Assessments
86
87
88
89
90
Scene Management
91
92
93
94
95
Assisting Partner
96
97
98
99
100
Phone/Radio Report
101
102
103
104
105
Transfer of Care
106
107
108
109
110
Documentation
*
1
2
3
4
5
Elite/Report Writing Skills
111
112
113
114
115
Post Call Duties
*
1
2
3
4
5
Return to service
116
117
118
119
120
Interpersonal Skills
*
1
2
3
4
5
Attitude
121
122
123
124
125
Communication
126
127
128
129
130
Multi-tasking Skills
131
132
133
134
135
Daily Duties
*
1
2
3
4
5
Cleaning
136
137
138
139
140
Documentation of areas that score 1 or 5 need explanation in comments. (If none write none)
*
Strengths observed during shift.
Weaknesses observed during shift.
Recommendations to work on for next shift
*
Additional Comments
Submit
Should be Empty: