Respiratory Therapist Student Internship Daily Performance Assessment

This form is for Internship Clinical Preceptors. Upon submission of this form, a copy will be sent to the student and clinical coordinator. You will also receive a receipt of your submission.

If you have any questions about this form, please contact Chris Becker at (608)246-6167 or

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4 Independent – consistently performs above standards of practice
3 Accomplished – performs at standards of practice
2 Developing – performs at minimum standards of practice
1 Dependent – performs below minimum standards of practice
CE Cannot Evaluate – did not observe this skill
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RT's, Nurses, Other allied health personnel (Required)
MD's, Residents (Required)
Patients and their families (Required)
Electronic charting accuracy (Required)
Verbal report (Required)
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Patient Histories (Required)
Patient Assessment (Required)
Equipment (Required)
Knows indications/side effects for therapies, ventilation, weaning (Required)
Makes appropriate recommendations for changes in therapy (Required)
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Arrives on time (Required)
Time management (Required)
Ethics and confidentiality (Required)
Respect for others (Required)
Always strives to improve (Required)