UMSL School of Social Work, MSW Program
Gerontology Concentration (revised 05/2014)
Agency Supervisor's Final Evaluation
Course 6800
Course 6850
Return forms: Hand-signed forms may be submitted in person or by fax to: (314) 516-6416. Forms sent as an email attachment to
socialwork@umsl.edu may be signed electronically provided the document is sent from the professional email address of the practicum
supervisor, and the student signer is copied. This fill form works best with a PC and Internet Explorer.
Student's Name:
Student ID#:
Semester:
Year:
Agency Name:
Supervisor's Name:
Phone:
Please complete the evaluation below by placing a check mark in the rating box that is appropriate for the student for
each practice behavior identified. Please use the comment area to discuss ways in which the competency was met
and to identify any areas in which you believe the student is particularly strong or those areas that need improvement.
*Practice behaviors in italics are specific to advanced practice in gerontology.
 Professional Identification: Identifies as a professional social worker and conducts oneself
accordingly (EPAS 2.1.1)
Unacceptable Deficient
Developing Accomplished Exemplary
1
2
3
4
5
Performance is
generally
unacceptable;
never meets
competency
Rarely
meets
competency
Advocates for client access to
the services of social work
Attends to professional roles
and boundaries
Understands and follows
agency policies and
procedures
Demonstrates professional
demeanor in behavior,
appearance, and
communication
Uses supervision and
consultation
Establishes and maintains
effective professional relations
with clients, co-workers,
representatives from other
disciplines and other agencies
1
Inconsistently
meets
competency
Consistently
meets
competency
Consistently
exhibits
mastery of
competency
Organizes time and plans
work accordingly
Demonstrates initiative and
resourcefulness in practicum
Understands agency's
mission, goals, function and
role
Assesses and addresses
values and biases
Understands the
perspective and values of
social work in relation to
working effectively with
other disciplines in geriatric
interdisciplinary practice
Engages in career-long
learning
Comments:

. Applies social work ethical principles to guide professional practice (EPAS 2.1.2)
Unacceptable
1
Deficient
2
Developing
3
Accomplished
4
Exemplary
5
Performance is
generally
unacceptable;
never meets
competency
Rarely
meets
competency
Inconsistently
meets
competency
Consistently
meets
competency
Consistently
exhibits
mastery of
competency
Demonstrates knowledge of,
and abides by, the NASW
Code of Ethics in practice
Recognizes and manages
personal values in a way that
allows professional values to
guide practice
Tolerates ambiguity in
resolving ethical conflicts
Applies strategies of ethical
reasoning to arrive at
principled decisions
2
Comments:

. Applies critical thinking to inform and communicate professional judgments (EPAS 2.1.3)
Unacceptable
1
Deficient
2
Developing
3
Accomplished
4
Exemplary
5
Performance is
generally
unacceptable;
never meets
competency
Rarely
meets
competency
Inconsistently
meets
competency
Consistently
meets
competency
Consistently
exhibits
mastery of
competency
Demonstrates effective oral
and written communication in
working with individuals,
families, groups,
organizations, communities,
and colleagues
Distinguishes, appraises, and
integrates multiple sources of
knowledge, including
research-based knowledge
and practice wisdom
Identifies problems and seeks
solutions by identifying options
while respecting different
values
Relates concepts and
theories of aging to social
work practice (e.g., cohorts,
normal aging, and life
course perspective)
Communicates to public
audiences through multiple
media, including writing
synthesis reports and
legislative statements
and/or orally presenting the
mission and outcomes of
the services of an
organization for a diverse
client group
3
Comments:
IV. Engages diversity and difference in practice (EPAS 2.1.4)
Unacceptable
1
Deficient
2
Developing
3
Accomplished
4
Exemplary
5
Performance is
generally
unacceptable;
never meets
competency
Rarely
meets
competency
Inconsistently
meets
competency
Consistently
meets
competency
Consistently
exhibits
mastery of
competency
Has sufficient self-awareness
to eliminate the influence of
personal biases and values in
working with diverse groups
Recognizes and
communicates understanding
of the importance of difference
in shaping life experiences
Views self as a learner, and
engages those with whom
he/she works as informants
Appreciates diversity among
older adult clients, families,
and professionals (e.g.,
class, race, ethnicity,
gender, and sexual
orientation)
Addresses the cultural,
spiritual, and ethnic values
and beliefs of older adults
and families
Comments:
V. Advances human rights and social and economic justice (EPAS 2.1.5)
4
Unacceptable
1
Deficient
2
Developing
3
Accomplished
4
Exemplary
5
Performance is
generally
unacceptable;
never meets
competency
Rarely
meets
competency
Inconsistently
meets
competency
Consistently
meets
competency
Consistently
exhibits
mastery of
competency
Engages in practice that
advances social and economic
justice
Recognizes that each person,
regardless of position in
society, has basic human
rights, such as freedom,
safety, privacy, an adequate
standard of living, health care
and education
Respects and promotes
older adult clients' right to
dignity and selfdetermination
Assesses and addresses
any negative impacts of
social and health care
policies on practice with
historically disadvantaged
populations
Comments:
VI. Engages in research-informed practice and practice-informed research (EPAS 2.1.6)
Unacceptable
1
Deficient
2
Developing
3
Accomplished
4
Exemplary
5
Performance is
generally
unacceptable;
never meets
competency
Rarely
meets
competency
Inconsistently
meets
competency
Consistently
meets
competency
Consistently
exhibits
mastery of
competency
5
Identifies the research base
for the work done at the
agency
Uses research evidence to
inform practice
Evaluates the effectiveness
of practice and/or programs
in achieving intended
outcomes
Comments:
VII. Applies knowledge of human behavior and the social environment (EPAS 2.1.7)
Unacceptable
1
Deficient
2
Developing
3
Accomplished
4
Exemplary
5
Performance is
generally
unacceptable;
never meets
competency
Rarely
meets
competency
Inconsistently
meets
competency
Consistently
meets
competency
Consistently
exhibits
mastery of
competency
Utilizes conceptual
frameworks to guide the
processes of assessment,
intervention, and evaluation
Demonstrates an
understanding of how
biological, psychological, and
cultural factors influence
human behavior
Demonstrates an
understanding about the ways
in which social systems
promote or deter people in
maintaining or achieving
health and well-being
Identifies issues related to
losses, changes, and
transitions over their life
cycle in designing
interventions
6
Comments:
VIII. Engages in policy practice to advance social and economic well-being and to deliver
effective social work services (EPAS 2.1.8)
Unacceptable
1
Deficient
2
Developing
3
Accomplished
4
Exemplary
5
Performance is
generally
unacceptable;
never meets
competency
Rarely
meets
competency
Inconsistently
meets
competency
Consistently
meets
competency
Consistently
exhibits
mastery of
competency
Identifies the role of policy in
service delivery
Collaborates with colleagues
and clients for effective policy
action
Understands organizational
policies, procedures and
resources that facilitate the
provision of services to
diverse clients
Comments:
IX. Responds to the contexts that shape practice (EPAS 2.1.9)
Unacceptable
1
Deficient
2
Developing
3
Accomplished
4
Exemplary
5
Performance is
generally
unacceptable;
never meets
competency
Rarely
meets
competency
Inconsistently
meets
competency
Consistently
meets
competency
Consistently
exhibits
mastery of
competency
Identifies and analyzes factors
that impact the agency's
mission and service delivery
system (i.e., organizational
structure, operation, policies,
funding, scientific
developments, economy, etc.)
7
Recognizes that the context of
practice is dynamic and has
the knowledge and skills to
respond proactively
Understands how a shared
organizational mission,
vision, values, and policies
respond to ever-changing
service systems to promote
coordinated optimal
services for older persons
Comments:
X. Engages, assesses, intervenes, and evaluates with individuals, families, groups,
organizations and communities (EPAS 2.1.10)
Unacceptable
1
Deficient
2
Developing
3
Accomplished
4
Exemplary
5
Performance is
generally
unacceptable;
never meets
competency
Rarely
meets
competency
Inconsistently
meets
competency
Consistently
meets
competency
Consistently
exhibits
mastery of
competency
Engagement
Substantively and affectively
prepares for action with
individuals, families, groups,
organizations, and
communities
Embodies the concept of
starting where the client is
Conveys respect for the client
Uses empathy and other
interpersonal skills
Assessment
Establishes rapport and
maintains effective working
relationships with older
adults and family members
Administers and interprets
standardized assessment
and diagnostic tools that are
appropriate for use with
older adults (e.g.,
depression scale, Mini-
8
Mental Status Exam)
Utilizes assessment data to
develop a mutually agreedon focus of work
Selects appropriate
intervention strategies
Intervention
Uses individual and/or
group interventions with
older adults and their
families (e.g., bereavement
groups, reminiscence
groups)
Provides social work case
management to link elders
and their families to
resources and services
Helps clients resolve problems
Negotiates, mediates, and
advocates for clients
Facilitates transitions and
endings
Evaluation
Critically analyzes, monitors,
and evaluates interventions
Comments:
Please describe the student’s primary strengths and areas for growth.
Strengths:
Growth Areas:
In what ways could the social work faculty have been more helpful to the agency or the student during the
course of the practicum?
Is your organization planning any changes (such as in staffing, programming, etc.) of which the University
should be aware? Please describe:
Please check the box next to the number that reflects your response to the following questions.
9
How would you rank this student’s effort in completing practicum tasks?
1. Consistent and outstanding
2. Consistent and above average
3. Consistent and average
4. Inconsistent and average
5. Inconsistent and below average
How would you rank this student’s level of knowledge and skill compared to a typical
advanced-practice level MSW student?
1. Outstanding
2. Above average
3. Average
4. Below average
5. Poor
If this is the student’s final semester in field placement, please provide your assessment of this
student’s readiness for entry level social work practice.
1. Surpasses expectations for entry level social work practice
2. Meets expectations for entry level social work practice
3. Meets expectations for entry level social work practice with the following exceptions:
4. Does not meet expectations for entry level social work practice. Please explain:
5. Does not apply. This student is not in his/her final semester of field placement
Please check the box to verify that the student has completed 300 practicum hours
Supervisor Signature
Date
Student Signature
Date
Return forms: Hand-signed forms may be submitted in person or by fax to: (314) 516-6416. Forms sent as an email
attachment to socialwork@umsl.edu may be signed electronically provided the document is sent from the professional
email address of the practicum supervisor, and the student signer is copied.
10