Medical Assistant Externship Booklet

MEDICAL ASSISTANT
EXTERNSHIP BOOKLET
(800) 927-5159 ● www.calregional.com

CMA04262019
Externship Booklet
This Externship Booklet includes important guidelines and documents for students to successfully complete
their externship. Students are required to bring their Externship Booklet with them to class and to their
externship each day. For more information, refer to the Student Handbook.
Students need to complete the information below:
Student Name:
Address:
Phone:
School/Program Attended:
Externship Site Name:

Address:
Phone:
Preceptor Name:
Externship Start Date:
Externship End Date:
Students will be required to attend externship sites during the hours assigned, which are fulltime and vary
from the program schedule. If the student declines a scheduled externship and/or the externship coordinator
is unable to contact the student, or the student is dropped from the externship site for any reason, the student
will be dropped from the program and not be eligible for a certificate or refund of any kind.
100% attendance is required at externship. Students must notify their externship site and their externship
coordinator if they have an emergency and have to miss a day. If a student does not call and does not show up
they are automatically dropped from the program.
COMPLETION CHECKLIST - complete and check off each box before sending in your externship booklet.
 Minimum 160 hours of externship
 Externship Sign-in Log
 Student Externship Evaluation - Completed by proctor
 Evaluation of Clinical Setting – Completed by student
 Scan and email a pdf of your externship booklet to [email protected] or
fax it to 707-927-0131.
Keep a copy for of your externship booklet for your records.
EXTERNSHIP BOOKLET DEADLINE

Students are required to turn in a completed Externship Booklet within 14 days of the last day of externship.
Students who do not turn in their Externship Booklet within 14 days of the last day of externship may be
dropped from the program and will not be issued a certificate or be eligible for a refund.
A NOTE TO THE PRECEPTOR
Thank you for hosting our healthcare training student. We appreciate your contribution to the success of our
students. Please contact CalRegional at (800) 927-5159 immediately if you have any questions or concerns.
This booklet contains all the paperwork required for the student to complete the program.
Here is a list of what we ask of you:
• Student’s Schedule: Verify student’s externship schedule.

• Externship Sign-In Log: Sign off on the dates and hours the student has completed on a daily basis.
• Student Evaluation Form: To be Completed by preceptor at the end of the externship.
Thank you again for your participation.

Health Care Portability and Accountability Act (HIPAA) Form
Dear Student,
Confidentiality: You are required to maintain confidentiality of patient information in accordance with state
and federal law. No student will have access to or have the right to review any medical record, except where
necessary in the regular course of the program. The discussion, transmission, or narration in any form by
students of any patient information obtained in the regular course of the program is forbidden except as
permitted by law. Please review and sign this Health Insurance Portability and Accountability Act (HIPAA)
form.
HIPAA STATEMENT
Notification of privacy practices in accordance with the Health Insurance Portability and Accountability Act
(HIPAA) was distributed and discussed during the classroom portion of this program. It is your responsibility as
a student to be able to define the HIPAA regulations. You should be able to describe how the regulation affects
you in your position in the allied healthcare field.
Please review the HIPAA notification thoroughly and keep it with your Externship Booklet.
I have read and understand the HIPAA regulations. (Please Print and Sign Your Name)
Print Name Signature Date

Externship Sign-in Form
Student Name:
DATE LOCATION HOURS SPENT PRECEPTOR’S INITIALS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Externship Sign in Form Continued
Student Name:
DATE LOCATION HOURS SPENT PRECEPTOR’S INITIALS
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
Attach additional time sheet if need

Student Externship Evaluation Form - Proctor
The Student Externship Evaluation should be filled out by the student’s preceptor on or before the last day
of externship. Fill in the student information below and ask your preceptor to complete the form.
Student Name:
Extern Site:
Start Date: End Date:
Please evaluate the above-named student in the following areas. Guidelines are as follows:
4 = excellent 3 = above average 2 = average 1 = needs improvement
PERFORMANCE
The student demonstrates:
Medical Assistant Student
Ability to learn and retain information 4 3 2 1 N/A

Correct techniques in paperwork procedures 4 3 2 1 N/A
Knowledge of collection/preparation of 4 3 2 1 N/A
specimens
Set-up and clean-up of patient care areas 4 3 2 1 N/A
Sufficient speed in completing task 4 3 2 1 N/A
Care of instruments and equipment 4 3 2 1 N/A
ATTITUDE

4 3 2 1 N/A
Interest in improving
4 3 2 1 N/A
Ability to learn new procedures
4 3 2 1 N/A
Punctuality/Attendance
4 3 2 1 N/A
Positive attitude
INITIATIVE

4 3 2 1 N/A
Ability to complete tasks
4 3 2 1 N/A
Undertaking of responsibilities
4 3 2 1 N/A
Anticipation of doctor ‘s / coworker’s needs
NEATNESS

Neatness in accomplishing work 4 3 2 1 N/A
Professionalism in personal appearance 4 3 2 1 N/A
PATIENT/STAFF RELATIONS

4 3 2 1 N/A
Ability to put patients at ease
4 3 2 1 N/A
Cooperation with staff
4 3 2 1 N/A
Ability to function under stress
4 3 2 1 N/A
Use of correct terminology
Please provide additional information on the student below.
Student appears to show strength in these areas:
Student could benefit from suggestions for improvement in these areas:
The overall appraisal of the student:
Outstanding_______ Above Average_______ Average_______ Unsatisfactory_______
Preceptor Signature:
Print Name: Date
Title: Phone:
Email address:
Site Name:
Address
Evaluation of Clinical Setting - Student
This form should be filled out by the student on or before the last day of the externship.
Instructions: Read each statement and mark your response on this form.
4 = Strongly Agree
3 = Agree
2 = Disagree
Medical Assistant Externship Site
1 = Strongly Disagree
N/A = Not Applicable
4 3 2 1 N/A
1. The number of patients/clients in the clinical setting was sufficient.
2. The variety of learning opportunities was sufficient.
3. The staff provided positive feedback.
4. There were sufficient resources (personnel and supplies) available.
5. Site staff created a supportive learning environment.
6. If hiring, the site would be a great place to work.

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MEDICAL ASSISTANT

(800) 927-5159 ● www.calregional.com

Externship Site Name:

EXTERNSHIP BOOKLET DEADLINE

Here is a list of what we ask of you:

• Student’s Schedule: Verify student’s externship schedule.

Thank you again for your participation.

Print Name Signature Date

DATE LOCATION HOURS SPENT PRECEPTOR’S INITIALS

DATE LOCATION HOURS SPENT PRECEPTOR’S INITIALS

Attach additional time sheet if need

4 = excellent 3 = above average 2 = average 1 = needs improvement

Medical Assistant Student

Ability to learn and retain information 4 3 2 1 N/A

Medical Assistant Student

Medical Assistant Student

Medical Assistant Student

Medical Assistant Student

Please provide additional information on the student below.

Student appears to show strength in these areas:

Student could benefit from suggestions for improvement in these areas:

The overall appraisal of the student:

Outstanding_______ Above Average_______ Average_______ Unsatisfactory_______

Print Name: Date

1. The number of patients/clients in the clinical setting was sufficient.

2. The variety of learning opportunities was sufficient.

3. The staff provided positive feedback.

4. There were sufficient resources (personnel and supplies) available.

5. Site staff created a supportive learning environment.

6. If hiring, the site would be a great place to work.

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Outstanding___ Above Average_ Average_ Unsatisfactory___