ࡱ> ` bjbjss :3%"""""""6yyy8y{6&^r0"ďďď}ٷ۷۷۷۷۷۷$h"""ďďd"ď"ďٷٷ""ďf `YyM0&o"u0"Ǟuuu%duuu&666UZ666Z666"""""" Appalachian State University Sociology and Social Work Department Field Instructors Final Evaluation of Students Field Experience Directions: This form may be completed on your computer. It should open automatically in Microsoft Word. Use the tab key to navigate through the questions. For the open ended questions, you may type as much as you like. Once completed print two copies, one for yourself and one for the student. Review the evaluation with the student intern. Both you and the student sign it. Student will turn evaluation into their field liaison. Name of Student:  FORMTEXT       Agency/Location:  FORMTEXT       Field Instructor:  FORMTEXT       Semester/Year:  FORMTEXT       Field Experiences: A. Caseload Number 1. Cases assigned during the semester.  FORMTEXT       2. Cases transferred or closed during the semester.  FORMTEXT       B. Weekly Schedule Average Hours Per Week 1. Interviews with clients/others  FORMTEXT       2. Recording  FORMTEXT       3. Supervisory conferences  FORMTEXT       4. Agency meetings  FORMTEXT       5. Other meetings  FORMTEXT       Comments on Field Experiences: Types of Cases Assigned:  FORMTEXT       Number and types of groups the student has worked with this semester:  FORMTEXT       Number and type of community experiences (outreach, resource development, advocacy, etc.) the student has been assigned this semester:  FORMTEXT       This evaluation form contains a list of objectives the student has been attempting to achieve. Please evaluate the students performance according to the rating scale explained below. Check one number that most accurately reflects your assessment. Comments and examples of student performance are encouraged. At this time, the students performance should be rated according to competencies the student should demonstrate by mid-point in the practicum experience. RATING SCALE 5 = Always 4 = Usually 3 = Sometimes 2 = Seldom 1 = Never NA = Not Applicable I. Agency Related Objectives 54321NA1Practices within the parameters of the stated purposes, goals and objectives of the agency. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 2Demonstrates the ability to assess the extent to which agency policies and procedures support or hinder service delivery. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 3Understands and appropriately applies agency policy and procedure.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 4Demonstrates a thorough knowledge of the local or area network of social services. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 5 Makes appropriate use of agency and community resources.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 6Understands social, economic, and political factors that affect agency services and clientele.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 7Identifies deficiencies in the service delivery network, and in agency services. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 8Contributes to agency staff meetings and committees.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 9Demonstrates an understanding of how organizational, inter-organizational and community relationships impact services to families, groups, and communities. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 10Participates in inter-agency meetings, community meetings, and/or community task groups. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Comments and examples:  FORMTEXT       II. Development of Professional Self 54321NA1Demonstrates knowledge of and adherence to the ethics of the social work profession. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 2Demonstrates respect for the positive value of diversity.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 3Distinguishes between a personal and professional relationship.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 4Identifies and acts to diminish the effects of personal prejudices and values in conflict with the values of the profession. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 5Encourages others to participate in decision-making, and respects the rights of others to differ. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 6Acts on personal limitations that impede practice efforts.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 7Independently seeks out knowledge-building experiences (readings, consultations, workshops, conferences, etc.) FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 8Maintains confidentiality.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 9Functions as a professional within the agency,  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Comments and examples:  FORMTEXT       III. Work Management 54321NA1Demonstrates effective use of time.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 2Independently plans work schedules appropriate for professional practice. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 3Completes necessary tasks promptly.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 4Keeps appropriate and complete records.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Comments and examples:  FORMTEXT       IV. Use of Field Instruction 54321NA1Accepts the field instructor s role.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 2Prepares appropriate agendas for supervisory conferences.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 3Submits appropriate recordings related to agendas.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 4Participates in identifying learning objectives and actively engages in learning. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 5Seeks guidance, yet demonstrates an appropriate level of independent functioning.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 6Engages in on-going evaluation of field performance and incorporates supervisory recommendations in practice efforts. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Comments and examples:  FORMTEXT       V. Provision of Services 54321NA1Engages the client system (individual, family, group, or community) in a mutual working relationship.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 2Assists client systems to move toward resolution of problem areas through effective use of self in the helping process. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 3Demonstrates acceptance of and empathy for all client systems.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 4Advocates for clients and applies strategies of change that advance social and economic justice. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 5Recognizes a wide range of emotional responses of clients (i.e. anger, grief, ambivalence.) FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 6Deals appropriately with various emotional responses of clients.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 7Gathers necessary and appropriate information from client systems and collateral contacts to make informed assessments. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 8Demonstrates the ability to make professional assessments of client problems. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 9Demonstrates the ability to independently formulate service plans and case goals with client system. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 10Demonstrates the ability to make appropriate referrals independent of supervision. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 11Integrates social work theory into practice.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 12Handles crisis situations effectively and with an appropriate amount of supervision. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 13Demonstrates (BSW level) professional skills in interviewing techniques. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 14Demonstrates (BSW level) professional skills in evaluating own intervention plans and methods. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 15Demonstrates (BSW level) professional skills in assessing client progress. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 16Demonstrates (BSW level) professional skills in transferring and terminating cases. 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FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 18Demonstrates (BSW level) professional skills in advocating for clients on both the micro- and macro-level. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 19Demonstrates (BSW level) professional skills in interventions with macro-level systems. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 20Demonstrates the ability to use the most effective level of intervention, i.e. micro or micro. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Comments and examples:  FORMTEXT       VI. Written Communication 54321NA1Prepares letters, reports and records that are clear, accurate, and appropriately written. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 2Prepares recordings suitable for agency records.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 3Prepares process recordings that reflect an understanding of theory, the intervention process, and the student role. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Comments and examples:  FORMTEXT  llllll*l+l,l-l.ll?l@lNlOlPlQlRl`lalblcldlrlsltlvlxlylllllllllmmmxmjvhUjhUjh_U!hh_B*OJQJaJphhx B*OJQJaJphh_hx j̫hUjVhUjhUjjhUjhUjh gUj~hUh g*ulvlkdB$$Iflִa^y!#%(3 t0|)6    44 lavlylllmm,m>mPm $Ifgd hv*$Ifgd_ $$Ifa$gdmm mmmmmm)m*m+m,m-m;mm?mMmNmOmQmSmTmmmmmmmmmmmmmmmmmmmmmmmmnyjhUjnhUjhUjhU!hh_B*OJQJaJphhx B*OJQJaJphhx jNhUjخhUjbhUjhUjh_Uh_/PmQmkdį$$Iflִa^y!#%(3 t0|)6    44 laQmTmmmmmmnn $Ifgd hv*$Ifgd_ $$Ifa$gdnnnnnnnnnnnzn{n|nnnnnnnnnnnnnnnnnnnnnnnnnnnnnn˺xjRhUjܵhUjfhUjhUjzhUjhU!hh_B*OJQJaJphhx B*OJQJaJphhx jвhUh_jh_UjZhU*nnkdF$$Iflִa^y!#%(3 t0|)6    44 lann{nnnnnnn $Ifgd h*$Ifgd $$Ifa$gdnnkdȶ$$Iflִa^y!#%(3 t0|)6    44 lannnooppFpHpJpLpPpTpXp\p`pfp $$Ifa$gd $Ifgd$ h*a$gd_gd6 h*gd6 h*gd gnnnnooo oop p pppppDpFpHplppΔ|kXHX8H4kh_h65B*OJQJaJphh_5B*OJQJaJph$hh65B*OJQJaJph!hh_B*OJQJaJph/jh_B*OJQJUaJmHnHphu0jh_hB*OJQJUaJph$jh_B*OJQJUaJphh6B*OJQJaJphh_B*OJQJaJph!hh6B*OJQJaJph$hh g5B*OJQJaJphfphpkd$$IflִYu!#%(hY3 t0|)6    44 lahplp"qFqjqqqqq $Ifgd h*$Ifgd_ $$Ifa$gdpp q"q$q@qBqDqFqHqdqfqhqjqlqqqqqqqqqqqqqqqqqqqr0r1r2r3rArBrCrDrErSrƻưƥƚƏƄuj0h_UhHy#jh_Ujh_Ujh_Ujh_Uj.h_Ujh_Uh_jh_U!hh_B*OJQJaJphhx B*OJQJaJphh_B*OJQJaJph+qqkdr$$IflִYu!#%(hY3 t0|)6    44 laqr1r2rDrVrhrzrrr $Ifgd $$Ifa$gd SrTrUrVrWrerfrgrhrirwrxryrzr{rrrrrrrrrrrrrrrssss%s&s's(s)s7s8s9s:s;sIs諝vj$h_Ujh_U!h,h_B*OJQJaJphh_B*OJQJaJph!hh_B*OJQJaJphjzh_Ujh_Ujh_Ujh_Uh_jh_Ujh_U+rrkd$$IflִYu!#%(hY3 t0|)6    44 larrs(s:sLs^spss $Ifgd h*$Ifgd $$Ifa$gdIsJsKsLsMs[s\s]s^s_smsnsospsqsssssssssssssssst责t[tYU0j0h_hB*OJQJUaJph$jh_B*OJQJUaJphh6B*OJQJaJphh_B*OJQJaJph!hh6B*OJQJaJph$hh_5B*OJQJaJphjh_Ujh_Ujh_Uh_jh_Ujh_Usskdr$$IflִYu!#%(hY3 t0|)6    44 lasssssxz46^`4 hj d^gd_ dgd_gdjgd6 h*gd_      General summary of student s progress and learning:  FORMTEXT       Your assessment of student s potential as a professional social worker:  FORMTEXT       I have read this evaluation. ___________________________________________ Student signature ___________________________________________ Field Instructor signature _________________________________________ Date NOTE: STUDENT MAY ATTACH AN ADDENDUM TO THIS REPORT.     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