Name of Evaluator/Instructor Mentor *

First Name

Last Name

Name of Instructor Candidate

First Name

Last Name

Practical Training Date *

Start Date of the Mentorship course

MM

DD

YYYY

Medical Knowledge/Skill

Candidate demonstrates command and understanding of medical subject matter including Base Medical's Wilderness Medicine Blended Learning Standards and management/treatment skills

Poor

Needs Work

Acceptable

Good

Excellent

Checkbox

Option 1

Option 2