ࡱ> ` <bjbj :(0%"""""""6~o~o~o8oZql6^tR"tttSVŐ$xh۪"OS۪""ttԫ===X"t"t===""=tt Vu1L~o;=ٛ0=vÔ"v=v"=Ւ0"='CՒՒՒ۪۪XՒՒՒ666NS666S666"""""" Appalachian State University Sociology and Social Work Department Field Instructors Mid-term 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 first half of the semester.  FORMTEXT       2. Cases transferred or closed during first half of 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 thus far this semester:  FORMTEXT       Number and type of community experiences (outreach, resource development, advocacy, etc.) the student has been assigned thus far this semester:  FORMTEXT       This evaluation form contains a list of objectives the student has been attempting to achieve. Please evaluate the student s 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 54321NA1Accurately identifies and defines the stated purposes, goals, and objectives of the agency. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 2Demonstrates an understanding of the agencys organizational structure. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 3Understands and appropriately applies agency policy and procedure.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 4Demonstrates a beginning knowledge of the local or area network of social services. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 5 Establishes professional relationships with agency personnel and professionals in other agencies and institutions. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 6Understands relevant social, economic, and political factors that impact agency services and clientele.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 7Adequately seeks out information within the agency.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 8Participates in agency staff meetings and committees.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 9Understands 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 2Identifies the effects of personal prejudices and values in conflict with the values of the profession. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 3Demonstrates an understanding of factors that distinguish a professional relationship from a personal relationship. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 4Encourages others to participate in decision-making, and respects the rights of others to differ. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 5Understands personal strengths and limitations as they relate to service delivery. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 6Maintains confidentiality.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 7Understands and has respect for the positive value of diversity.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Comments and examples:  FORMTEXT       III. Work Management 54321NA1Demonstrates effective use of time.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 2Shows good judgment and self-direction in planning work schedules.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 3Completes forms, recordings, reports, and dictations 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 agendas for supervisory conferences addressing: (a) client system problems; (b) intervention techniques; (c) community resources; (d) agency policies and procedures; (e) learning goals; and (f) reactions to and concerns about field experiences. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 3Submits appropriate recordings related to agendas.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 4Seeks guidance and actively engages in learning.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 5Engages 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 2Demonstrates acceptance of and empathy for all client systems.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 3Explores and responds to client feelings about problems.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 4Gathers necessary and appropriate information from client systems and collateral contacts to make informed assessments. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 5Demonstrates the ability, with supervisory guidance, to formulate service plans and appropriate goals with client systems. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 6Understands the inter-relationships among multiple factors contributing to client system problems. problems. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 7Identifies forms and mechanisms of oppression and discrimination that affect clients. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 8Assists client systems in making effective use of community resources through adequate case follow-up and appropriate referrals. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 9Demonstrates knowledge of social work theory and the ability to integrate theory and practice. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 10Demonstrates beginning level skills in interviewing techniques.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 11Demonstrates beginning level skills in evaluating own intervention plans and methods. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 12Demonstrates beginning level skills in assessing client progress.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 13Demonstrates beginning level skills in transferring and terminating cases. 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FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 15Demonstrates beginning level skills in advocating for clients on both the micro- and macro-level. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 16Demonstrates beginning level skills in interventions with macro-level systems. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 17Identifies the most effective level of intervention, i.e., micro or macro. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  Comments and examples:  FORMTEXT       VI. Written Communication 54321NA1Prepares letters, reports and records that are appropriately and clearly written and that reflect the purpose to be achieved. 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       General summary of student s progress and learning goals:  FORMTEXT       Plans for the student during the remainder of placement:  FORMTEXT       I have read this evaluation. HHHHHH I IIIIII-I.I/I0I1I?I@IAIBICIQIRISITIUIcIdIeIfIgIuIvIwI|IIIIIIIIIII|jvhUjBhUj̙hUjVhUjhUjjhUjhUh_B*OJQJaJph!hh_B*OJQJaJphh_jh_UjhU.HHkd6$$Iflִa^y!#%(hY3 t0|)6    44 laHH II0IBITIfIxI $Ifgd hv*$Ifgd_ $$Ifa$gdxIyIkd$$Iflִa^y!#%(hY3 t0|)6    44 layI|IIIIJJ%J7J $Ifgd h*$Ifgd $$Ifa$gdIIIIIIIJJJJJJJJ"J#J$J%J&J4J5J6J;JPQR~ d^gd_ dgd_ d^gd6gd6 h*gd_OOOOP P PP P"P6P8PJPLPdPfPvPxPPPPPPPPPPPPPPPPP QQ Q"Q$Q&Q흌ߌߌߌߌߌ~e흌ߌߌߌߌ~0jh_hB*OJQJUaJphh6B*OJQJaJph!hh6B*OJQJaJph!hh_B*OJQJaJph/jh_B*OJQJUaJmHnHphu0j,h_hB*OJQJUaJphh_B*OJQJaJph$jh_B*OJQJUaJph'&Q:QQHQJQLQNQQR>R~ф؄لŭŜ}{}mm_RJFJFJFhTjhTUhh6OJQJaJhAB*OJQJaJphhV3B*OJQJaJphUhoB*OJQJaJph!hh6B*OJQJaJph!hh_B*OJQJaJph/jh_B*OJQJUaJmHnHphu$jh_B*OJQJUaJph0jh_hB*OJQJUaJphh_B*OJQJaJph ___________________________________________ Student signature ___________________________________________ Field Instructor signature _________________________________________ Date NOTE: STUDENT MAY ATTACH AN ADDENDUM TO THIS REPORT.     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