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NATIONAL GUIDELINES FOR EDUCATING EMS INSTRUCTORS
AUGUST 2002
APPENDIX IV: Student Counseling Report (Sample)
This counseling report will be made part of the following student’s file.
Student Name: ____________________________ Date: _______________
Person Issuing Counseling: __________________ Title: _______________
Section I:
Behavioral: The following deficiency has been noted in your behavior while
participating in the Emergency Medical Services program.
Penalty: First offense will be met with a counseling. Second offense will be met with a
one-week suspension from participation in the program. Third offense will be met with a
failing grade in the course and the possibility of permanent discharge from the program.
A first or second offense, if judged severe enough by the program coordinator, can lead
to a failing grade in the course and the possibility of permanent discharge from the
program.
1) Integrity: Being of sound moral principle; honesty and sincerity.
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2) Empathy: An understanding of another person’s situation / illness.
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3) Self-Motivation: The ability to show inner drive toward good intention.
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4) Appearance / Personal Hygiene: Neat, clean and non-malodorous.
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5) Teamwork and Diplomacy: Working in a cooperative manner with respect for
others.
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6) Respect: To show consideration with deference or courtesy.
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7) Patient Advocacy: Acting in the best interest of / for the patient.
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