Ball State University
Department of Social Work
(765) 285-1016
VOLUNTEER / FIELD LEARNING CONTRACT AND EVALUATION
Instructions: The back of this form should be signed by the student and the site supervisor or Student Volunteer
Services coordinator. A xeroxed copy of this form should be turned into the instructor initially after the goals are
established, and then again at the end of the semester when the final evaluation is completed.
I.
INTRODUCTION
Through the social work program’s required volunteer field experiences, the student has the opportunity to
assume a participant-observer helper role in a human service-like or based organization. Due to the
importance of this required learning experience, part of your evaluation will be based on the successful
completion of this volunteer field experience. The class instructor will identify specific goals for the
volunteer experience. You will also be required to identify personal learning goals for the volunteer field
experience which you will list on this form.
II.
VOLUNTEER / FIELD ASSIGNMENT INFORMATION
A.
Student: _______________________________ BSU I.D.: _______________________________
Phone: (_____)______ _______ Email: ______________________________________________
Social Work Course: SOCWK 200 ____
B.
SOCWK 400____
Agency / Setting _______________________________________________________________
Supervisor _________________________Address _____________________________________
Phone : (_____)______ _______ Email ______________________________________________
C.
Student’s Personal/Professional Learning Goals:
1.
2.
3.
4.
5.
During this semester I, ________________________________agree to participate in a volunteer
field experience at the above agency / setting beginning___________(date), averaging
__________hours per week for a total of ___________ hours. I agree to complete these field
experience hours by ___________(date) and will be under the supervision of
________________________________(name).
_______________________________________
Student Signature
D.
________________
Date
Supervisor / SVS Program Coordinator:
I have reviewed this student’s Learning Contract and Evaluation form, and understand I will be asked to
complete a final evaluation on this student’s performance in the above volunteer field experience.
I have reviewed this student’s Learning Contract and Evaluation form, and understand I will be asked to
complete a final evaluation.
_______________________________________
Supervisor Signature
________________
Date
II.
EVALUATION OF VOLUNTEER EXPERIENCE
Policies and Procedures
To protect the recipients of the volunteer service, the following policies and procedures apply to
the volunteer field experience:
1.
Students must request and secure, or initiate a commitment to a volunteer field
assignment by the end of the third full week of the semester in order to receive credit for
this class assignment. If this is not done, a written explanation for not doing so must be to
the instructor at the next class meeting. In such cases the instructor will determines if an
alternative assignment is warranted.
2.
If Section I of the learning contract, for any reason, is not completed, an assignment by
the field agency site or Student Voluntary Services (SVC) will not be given.
3.
Through assuming responsibility in the volunteer field experience, students are expected
to learn about the related social service delivery system, and demonstrate basic
competency in interpersonal relations and self reflection.
4.
Evaluation of performance at the end of the assignment will be done by the supervising
person identified in Section I. The student is responsible for obtaining the completed
evaluation form from his/her supervisor, and returning the form to the instructor. The final
evaluation form becomes part of the application materials submitted for formal admission
to the major, and as such becomes part of the student’s academic file located in the social
work department’s office. The student has access to her/his file.
5.
Assignments, as specified in the course syllabus, must be completed and submitted to the
instructor.
6.
Any student found falsifying the documentation of volunteer field hours, log entries, or the
final evaluation form will receive an automatic “F” for the Volunteer Field Experience
assignment for the class.
7.
Students are expected to abide by the policies and expectations of the volunteer field
agency site in regards to attendance, punctuality, dress, paperwork, ethical standards
(e.g. confidentiality), and the carrying out volunteer responsibilities. Students who violate
site policies may not be permitted to continue in the volunteer field experience and this will
be reflected in their final grade for the Volunteer Field Experience assignment.
2
Final Volunteer Field Experience Evaluation Form
Supervisor Instructions:
Please check any of the following to describe the basis for evaluating the student’s performance.
Check all that apply.
_____
_____
_____
_____
_____
1.
2.
3.
4.
5.
Direct Observation
Co-Worker Feedback
Client Feedback
Performance in Training Sessions
Other (please specify) ____________________________
How well did the student perform in the following areas? Please circle the number which best
describes your assessment of how well the student performed in each area described. The
“For Office Use Only” column translates ratings into practice competency assessment data.
N/A
1
2
3
4
5
NOT
APPLICABLE
NEVER MEETS
EXPECTATIONS
RARELY MEETS
EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
ALWAYS EXCEEDS
EXPECTATIONS
The student
consistently performs
below a level that
would be expected for
a bachelor-level social
worker. Shows little to
no evidence of
understanding the
concept and/or ability
to effectively apply the
skill.
The student frequently
performs at a level
below what would be
expected for a
bachelor-level social
worker.
The student reliably
performs at a level that
would be expected for a
bachelor-level social
worker.
The student frequently
performs at a level
above what would be
expected for a
bachelor-level social
worker.
The student
consistently performs
at a level above what
would be expected for
a bachelor-level social
worker.
There has not yet
been the opportunity
to develop and
practice this skill.
A.
Demonstrated an understanding of the overall agency purpose and organizational
structure.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
For
Office
Use
Only
10.1
ALWAYS EXCEEDS
EXPECTATIONS
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
B.
Functioned well within the structure of the volunteer field agency setting.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
ALWAYS EXCEEDS
EXPECTATIONS
1.3
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
C.
Set appropriate learning goals and actively sought to accomplish these goals.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
ALWAYS EXCEEDS
EXPECTATIONS
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
3
1.5
D.
Familiarized her/himself with the volunteer field agency’s policies and goals and
worked effectively with these policies and goals.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
10.1
ALWAYS EXCEEDS
EXPECTATIONS
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
E.
Conducted him/herself professionally when at the volunteer field agency site.
1.3
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
ALWAYS EXCEEDS
EXPECTATIONS
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
F.
Attended regularly and on time, or informed the volunteer field agency setting
ahead of time of absences.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
1.4
ALWAYS EXCEEDS
EXPECTATIONS
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
G.
Dressed appropriately for the volunteer field agency setting.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
1.4
ALWAYS EXCEEDS
EXPECTATIONS
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
H.
Sustained effort with assignments/clients and followed through on
responsibilities.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
10.9
ALWAYS EXCEEDS
EXPECTATIONS
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
I.
Demonstrated an understanding of the student volunteer’s role in providing
services, and successfully assumed this role.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
1.3
ALWAYS EXCEEDS
EXPECTATIONS
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
J.
Maintained appropriate boundaries in relationships and other behaviors.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
ALWAYS EXCEEDS
EXPECTATIONS
1.3
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
K.
Related in a sensitive, genuine, and respectful manner to clients and staff.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
10.2
ALWAYS EXCEEDS
EXPECTATIONS
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
L.
Communicated effectively verbally and nonverbally.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
ALWAYS EXCEEDS
EXPECTATIONS
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
4
1.4
3.3
M.
Demonstrated the ability to listen effectively.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
ALWAYS EXCEEDS
EXPECTATIONS
10.2
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
N.
Demonstrated empathy when providing services.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
ALWAYS EXCEEDS
EXPECTATIONS
10.2
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
O.
Maintained confidentiality in performing volunteer/field responsibilities.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
ALWAYS EXCEEDS
EXPECTATIONS
2.2
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
Q.
Developed positive relationships with clients and staff from backgrounds
dissimilar from their own. (age, class, color, disability, ethnicity, family structure,
gender, gender identity, marital status, national origin, race, religion, sex, and sexual orientation)
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
4.2
4.3
4.4
ALWAYS EXCEEDS
EXPECTATIONS
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
R.
Demonstrated an awareness of the economic, social, and political factors that
adversely affect clients being served by the volunteer field agency.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
5.1
5.2
ALWAYS EXCEEDS
EXPECTATIONS
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
S.
Advocated appropriately for the clients being served by the agency.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
5.3
ALWAYS EXCEEDS
EXPECTATIONS
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
T.
Sought supervision and constructive feedback regarding her/his performance.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
1.6
ALWAYS EXCEEDS
EXPECTATIONS
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
U.
Demonstrated the ability to learn through observation.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
ALWAYS EXCEEDS
EXPECTATIONS
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
5
4.4
7.1
V.
Demonstrated self-confidence in performing volunteer responsibilities.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
ALWAYS EXCEEDS
EXPECTATIONS
1.4
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
W.
Demonstrated Initiative in performing volunteer/field responsibilities appropriate
assertiveness skills.
NOT
APPLICABLE
NEVER MEETS RARELY MEETS
EXPECTATIONS EXPECTATIONS
MEETS
EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
ALWAYS EXCEEDS
EXPECTATIONS
N/A - - - - - - 1 - - - - - - - - - 2 - - - - - - - - - - 3 - - - - - - - - - - 4 - - - - - - - - - - 5
------------------------------------------------------------------------------------------------------------------------------------------X.
Did the student fulfill their time and professional commitment to the field agency site?
1._____Yes
2._____No
If no, please explain:
Y.
According to your records, how many hours did the student volunteer at your field
agency? _______________
Z.
How many absences occurred, which the student did not make up? ______________
Would you be willing to work with this student again? Please explain.
6
1.2
1.4
SUPERVISOR’S OVERALL EVALUATION
I rate this student’s overall performance in this volunteer field experience as:
NOT
APPLICABLE
NEVER MEETS
EXPECTATIONS
RARELY MEETS
MEETS
EXPECTATIONS EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
ALWAYS EXCEEDS
EXPECTATIONS
N/A - - - - - - - - - 1 - - - - - - - - - - - - - 2 - - - - - - - - - - - - - 3 - - - - - - - - - - - - 4 - - - - - - - - - - - - - - - 5
Please elaborate on this student’s strengths and weaknesses:
_______________________________________
________________
Supervisor Signature
Date
STUDENT’S OVERALL SELF EVALUATION
1.2
I rate my overall performance in this volunteer experience as:
NOT
APPLICABLE
NEVER MEETS
EXPECTATIONS
RARELY MEETS
MEETS
EXPECTATIONS EXPECTATIONS
OFTEN EXCEEDS
EXPECTATIONS
ALWAYS EXCEEDS
EXPECTATIONS
N/A - - - - - - - - - 1 - - - - - - - - - - - - - 2 - - - - - - - - - - - - - 3 - - - - - - - - - - - - 4 - - - - - - - - - - - - - - - 5
Please elaborate:
_______________________________________
Student Signature
________________
Date
Revised 8/30/12
7