INDIANA UNIVERSITY OF PENNSYLVANIA
Department of Educational and School Psychology
1175 Maple Street
Indiana, PA 15705
(724) 357-2316

Neuropsychology Evaluation Form

Date: _________________

Name of Student: __________________ Placement: ______________________

Evaluator: ________________________ Evaluator's Title: __________________

DIRECTIONS: The Internship experience is an essential component in the student’s clinical experience. Ratings are intended to guide the student and the program in evaluating readiness for independent practice. Please use the following rating scale in evaluating the students on the characteristics listed below:

N/A - Not Applicable; Not an appropriate goal for a school psychology practicum in this setting.

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 for practice in schools. 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.

A. PERSONAL CHARACTERISTICS

1.	Presents a good personal appearance	N/A	0	1	2	3	4	5
2.	Demonstrates dependability	N/A	0	1	2	3	4	5
3.	Meets difficult situations with self control	N/A	0	1	2	3	4	5
4.	Demonstrates good judgment and common sense	N/A	0	1	2	3	4	5
5.	Communicates and listens effectively	N/A	0	1	2	3	4	5
6.	Shows concern, respect, and sensitivity for the needs of staff and clients (patients)	N/A	0	1	2	3	4	5
7.	Works well with other staff	N/A	0	1	2	3	4	5
8.	Is able to relate well to clients	N/A	0	1	2	3	4	5
9.	Utilizes constructive criticism	N/A	0	1	2	3	4	5
10.	Displays initiative and resourcefulness	N/A	0	1	2	3	4	5
11.	Demonstrates tolerance for other's values and viewpoints	N/A	0	1	2	3	4	5
12.	Accepts constructive criticism	N/A	0	1	2	3	4	5
13.	Shows evidence of continued self-evaluation	N/A	0	1	2	3	4	5
14.	Achieves comfortable interactions with minority clients	N/A	0	1	2	3	4	5

B. ASSESSMENT SKILLS

1.	Clearly identifies the nature of the referral problem and the purpose of the assessment	N/A	0	1	2	3	4	5
2.	Uses appropriate assessment instruments that are directly related to the identified problem	N/A	0	1	2	3	4	5
3.	Analyzes and interprets test results in a meaningful and thorough fashion	N/A	0	1	2	3	4	5
4.	Makes recommendations that follow logically from the assessment results and are meaningful for the client	N/A	0	1	2	3	4	5
5.	Displays accuracy in administering tests	N/A	0	1	2	3	4	5
6.	Displays accuracy in scoring tests	N/A	0	1	2	3	4	5
7.	Is sensitive to sources of bias when selecting and administering tests	N/A	0	1	2	3	4	5

C. CONSULTATION SKILLS

1.	Establishes effective collaborative	N/A	0	1	2	3	4	5
2.	Conducts effective conferences with clients and allied professionals	N/A	0	1	2	3	4	5
3.	Serves effectively as a liaison for school and clients	N/A	0	1	2	3	4	5
4.	Evaluates effectiveness of consultation strategies used	N/A	0	1	2	3	4	5

D. INTERVENTION SKILLS

1.	Uses intervention strategies that are directly related to the assessed problem	N/A	0	1	2	3	4	5
2.	Clearly delineates goals of intervention goals	N/A	0	1	2	3	4	5
3.	Evaluates the effectiveness of intervention techniques used	N/A	0	1	2	3	4	5
4.	Demonstrates skill in utilizing individual counseling techniques (where appropriate)	N/A	0	1	2	3	4	5
5.	Demonstrates skill in utilizing group counseling techniques (where appropriate)	N/A	0	1	2	3	4	5
6.	Demonstrates skill in utilizing remediational techniques	N/A	0	1	2	3	4	5

E. PROFESSIONAL RESPONSIBILITIES

1.	Observes scheduled hours of appointments at assigned department(s) in a punctual manner	N/A	0	1	2	3	4	5
2.	Is prompt in meeting deadlines, responding to referrals, and handing in written reports	N/A	0	1	2	3	4	5
3.	Completes written reports and forms in a neat, thorough, and accurate manner	N/A	0	1	2	3	4	5
4.	Writes reports in a coherent, focused, and well organized manner	N/A	0	1	2	3	4	5
5.	Establishes appropriate work priorities and manages efficiently	N/A	0	1	2	3	4	5
6.	Keeps supervisors and administrators informed of unusual events and activities, as well as routine matters in their department(s) (where appropriate)	N/A	0	1	2	3	4	5
7.	Uses feedback from supervision in a productive manner	N/A	0	1	2	3	4	5
8.	Consistently follows through when additional action is needed	N/A	0	1	2	3	4	5
9.	Demonstrates an awareness of competency level, and doesn't accept responsibilities that exceed this level	N/A	0	1	2	3	4	5
10.	Maintains visibility and accessibility within assigned department(s)	N/A	0	1	2	3	4	5
11.	Considers all alternatives and implications before recommending a change in client’s program	N/A	0	1	2	3	4	5

OVERALL RATING OF STUDENT

N/A

0

1

2

3

4

5

Rating Period: ________ (0-100 hrs.): ________ (101-200 hrs.): ________ (201-300 hrs.)

Number of supervised hours completed to date: _______________________

Hours of direct supervision for this rating period: _______________________

PROFESSIONAL GOALS:

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

1. My most important goal ____________________________________________________________________ ________________________________________________________________________

2.______________________________________________________________________
________________________________________________________________________

3.______________________________________________________________________
________________________________________________________________________

Evaluator's signature: __________________________________ Date: _____________

Student's signature: _____________________________________ Date: _____________

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

From Best Practices in School Psychology Volume II. Developed by Marc Cecil, University of South Carolina, and adapted to present form by school psychology program, University of Wisconsin-Madison.

Please return the completed form (with signatures) to:

Gurmal Rattan, Ph.D.

1175 Maple St.

246 Stouffer Hall

Indiana University of Pennsylvania

Indiana, PA 15705-1087

Email: gurmalra@iup.edu Voice: (724) 357-3787 Fax: (724) 357-6946