Interdepartmental
Graduate Concentration
in Survey Research Methodology
PRECEPTOR’S EVALUATION OF PRACTICUM (PA-579) OFF CAMPUS
Semester ____________ Year _______ Credit Hours _____
Student’s name _________________________________________________
Practicum site name ________________________________________ City/State ______________________
Preceptor’s name __________________________________________ Title ___________________________
Address _______________________________________________________________________________
e-mail __________________ Phone _____________________
Start Date: _____________________ End Date: _____________________ Average hours/week: _________
Please circle the number that corresponds to your response to each of the following questions.
During this practicum experience, how much did the student …
Not at All
Very Much
1. Demonstrate a developing knowledge of
survey research methodology? ..........................................................
1
2
3
4
5
2. Demonstrate development in his/her skills in
survey research methodology? ..........................................................
1
2
3
4
5
3. Become engaged in day-to-day aspects of
survey research practice? ..................................................................
1
2
3
4
5
4. Work at the highest level of his/her ability? .......................................
1
2
3
4
5
5. Achieve all of his/her learning objectives? .........................................
1
2
3
4
5
6. Contribute to the project(s) to which he/she was assigned? .............
1
2
3
4
5
7. Demonstrate ability to work independently, as appropriate? .............
1
2
3
4
5
8. Complete assignments on schedule? ................................................
1
2
3
4
5
9. Complete assignments with the expected level of quality? ...............
1
2
3
4
5
10. Work effectively with you, as his/her preceptor? ...............................
1
2
3
4
5
11. Work effectively with other staff? .......................................................
1
2
3
4
5
GCSRM 8/07
2
12. Overall, how do you rate this student’s performance in this practicum?
Poor
1
Excellent
2
3
4
5
13. Do you recommend that your site should be considered for future practica in the UIC Interdepartmental
Graduate Concentration in Survey Research Methodology?
Yes .............................................
1
No ...............................................
2
14. Are you willing to consider serving as a preceptor for future practica in the UIC Interdepartmental Graduate
Concentration in Survey Research Methodology?
Yes .............................................
1
No ...............................................
2
15. In the space below, please enter your comments about your experience as preceptor for this practicum and
the student’s performance.
Signature ____________________________________________________
Date
_________________
Please place the original of this form in a sealed envelope, with your signature across the seal.
Then give it to the student, who will submit it along with his/her final practicum report.
GCSRM 8/07