INDIANA UNIVERSITY OF PENNSYLVANIA

Indiana, Pennsylvania

Family-School Specialization Intern Evaluation

NAME OF STUDENT: ____________________________________________________              DATE: ________________

EVALUATOR:  __________________________________________________________ 

                                    (Title)                           (Name)

PLACEMENT:  __________________________________________________________

DIRECTIONS:  This rating form is intended to provide the student with formative feedback.  To that end, it should provide a meaningful learning opportunity for the student.  Please complete this form after each 100 hours of supervision.  Given that 300 hours of supervised internship are required, this form should be completed three times.  Thank you for taking the time to complete this form.  Please use the following rating scale in evaluating the student on the characteristics listed below:

N/A -   Not Applicable:  Goal was not addressed during this 100 hour period.

0 -        Not observed

1 -        Unsatisfactory:   Student’s skills reflect insufficient mastery in this area; Student needs additional course-based instruction in this skill.

2 -        Needs improvement:   Plans should be made to insure student gains extra practice in this skill prior to leaving the program.

3 -        Satisfactory:   Student’s skills in this area are adequate.  Student should continue to practice this skill under professional supervision.

4 -        Competent:  Student is comfortably independent in this skill.

5 -        Outstanding:  Student’s skills in this area are exceptionally strong; Student could be a model practitioner in this skill area.


Personal Characteristics

Not Applicable

N/A

Not

Observed

0

Unsatisfactory

1

Needs

Improvement

2

Satisfactory

3

Competent

4

Outstanding

5

Presents a good personal appearance

Demonstrates dependability

Meets difficult situations with self-control

Demonstrates good judgment and common sense

Communicates and listens effectively

Shows concern, respect, and sensitivity for the needs of staff, and clients/students

Works well with other staff

Is able to relate well to children/adults

Utilizes constructive criticism

Displays initiative and resourcefulness

Demonstrates tolerance for other’s values and viewpoints

Shows evidence of continued self-evaluation


Assessment and Therapeutic Interventions with Families and Schools

Not Applicable

N/A

Not

Observed

0

Unsatisfactory

1

Needs

Improvement

2

Satisfactory

3

Competent

4

Outstanding

5

Identifies family problems within a systems framework

Is able to set clear therapeutic goals

Is able to establish rapport and join with all family members

Is able to make each member of the family feel understood and accepted

Is able to identify the emotional needs of the family

Asks questions in a non-blaming way

Is able to reframe problems effectively

Is able to manage family conflict within the session

Is able to generate appropriate homework activities for the family

Is able to provide skill training in communication and problem-solving when necessary

Is able to provide parent training when necessary

Is able to identify family resistance to treatment when it occurs

Is able to structure homework assignments for the family to facilitate completion

Is comfortable responding to sensitive, emotional issues within the session

Is able to develop a collaborative set between family and school

Is able to identify family strengths

Is able to utilize family strengths as part of the therapeutic process

Professional Responsibilities

Not Applicable

N/A

Not

Observed

0

Unsatisfactory

1

Needs

Improvement

2

Satisfactory

3

Competent

4

Outstanding

5

Observes scheduled hours of appointments as assigned in a punctual manner

Is prompt in meeting deadlines, responding to referrals, and handing in written reports

Writes reports in a coherent, focused, and well-organized manner

Establishes appropriate work priorities and manages them efficiently

Consistently follows through when additional action is needed

Demonstrates an awareness of competency level, and doesn’t accept responsibilities that exceed this level

Not Applicable

N/A

Not

Observed

0

Unsatisfactory

1

Needs

Improvement

2

Satisfactory

3

Competent

4

Outstanding

5

Overall Rating of Student


PROFESSIONAL GOALS:

Given the above ratings of the student’s current professional skills, list the three most important goals (if necessary) which should be established for his/her continued professional training.

  1. Most important goal _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
  2. _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
  3. _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Rating period: _______ (0-100)  _______ (101-200)  _______ (201-300)

Number of supervised hours completed: __________________________________________________

Hours of direct supervision for this rating period: ___________________________________________

_____________________________________________________              __________________________

Evaluator’s Signature                                                                                        Date

_____________________________________________________              __________________________

Student’s Signature                                                                                           Date

(The student’s signature indicates only that the evaluation has been discussed with the student.)

Please return the completed form (with signatures) to:

Victoria B. Damiani, Ed.D., NCSP

Indiana University of Pennsylvania

246C Stouffer Hall

Indiana, PA  15705