Submit by Email APPENDIX J UNIVERSITY SUPERVISOR EVALUATION Instructions: This form is to be completed by the student and submitted to the address identified at the end of the form. This form will be kept confidential from the university supervisor until the end of the academic year and until at least five such forms are accumulated. Name:_______________________________ Date:___________________ Site of Internship:_________________________________________________________ Please answer each of the following questions. If you need additional space, attach separate sheets. At no time will the supervisor see the original evaluation from the student. All information will appear in aggregate format based on at least five evaluations. All final grades will be posted before any internship aggregate evaluation information will be shared with the university supervisor. All evaluation feedback is completely confidential and the university supervisor will not be able to identify the source of any comment. Please circle the appropriate response for each statement. 1) The university supervisor distributed the internship manual. Strongly Agree Agree Disagree Strongly Disagree 2) The university supervisor went over the internship manual. Strongly Agree Agree Disagree Strongly Disagree 3) The university supervisor notified me of all logs, reports, journals or other required assignments that were part of the successful completion of the internship. Strongly Agree Agree Disagree Strongly Disagree 4) The university supervisor informed me of all due dates for the required assignments that were part of the successful completion of the internship. Strongly Agree Agree Disagree Strongly Disagree 5) The university supervisor completed evaluations as specified in the internship manual. Strongly Agree Agree Disagree Strongly Disagree 6) The university supervisor visited your site at least once during your internship. Strongly Agree Agree Disagree Strongly Disagree 7) The university supervisor appropriately notified me for any missing assignments or for not fulfilling my assigned duties in my internship. Strongly Agree Agree Disagree Strongly Disagree 8) The university supervisor provided me with sufficient opportunity to interact either by email, on site, or by phone. Strongly Agree Agree Disagree Strongly Disagree Print Form 9) The university supervisor communicated with me at a level consistent with my professional development. Strongly Agree Agree Disagree Strongly Disagree 10) The university supervisor was readily available to me in order to answer my questions or discuss any concerns I might have about the internship. Strongly Agree Agree Disagree Strongly Disagree 11) The university supervisor conveyed specific areas of strengths or weaknesses to me. Strongly Agree Agree Disagree Strongly Disagree 12) The university supervisor showed respect for me as an individual during any conference or evaluation? Strongly Agree Agree Disagree Strongly Disagree 13) The university supervisor appropriately encouraged me to become an independent/ autonomous professional. Strongly Agree Agree Disagree Strongly Disagree 14) The university supervisor maintained confidentiality about my performance during the internship. Strongly Agree Agree Disagree Strongly Disagree 15) The university supervisor encouraged me to initiate strategies for future professional experiences. Strongly Agree Agree Disagree Strongly Disagree 16) The university supervisor encouraged me to reflect on my internship experience. Strongly Agree Agree Disagree Strongly Disagree In the space provided below, please make any specific comments concerning the university supervisor. PLEASE RETURN THE COMPLETED FORM IN THE SELF-ADDRESSED ENVELOPE.