Foundation Year Field Placement Student Self-Evaluation Form
College of Community and Public Affairs
Department of Social Work
CONTACT INFORMATION
Student Name:
Student Email:
Agency:
Address:
City:
Field Instructor Name:
Field Instructor Email:
Field Liaison Name:
Field Liaison Email:
Semester:
Course:
SW 591 □
SW 592 □
Fall □
Spring □
State:
Zip:
Phone:
Year:
20___
Summer □
Duties and Responsibilities: (Briefly describe the kinds of learning experiences you completed. The types and
numbers of cases assigned should be included.)
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Use of evaluation form: This form should be completed once at the end of each semester you are in field. If
you rate yourself either at either level 1 or 5, you must comment in the space provided. Note: You will
not be graded based on your responses below.
Using the scale below, rate how capable you assess yourself to be in performing each of the following practice
behaviors:
NA = No opportunity to complete the practice behavior
1 = Unable to perform the basic requirements of the practice behavior
2 = Sometimes able to perform the basic requirements of the practice behavior but not always
3 = Consistently able to perform basic requirements of the practice behavior
4 = Consistently able to perform basic requirements of the practice behavior and occasionally
exceeds expectations
5 = Consistently exceeds performing the basic requirements of practice behavior
Competency 1: Demonstrate Ethical and Professional
Behavior
End of First
Semester Rating
(SW 591)
End of Second
Semester Rating
(SW 592)
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
3. Demonstrate professional demeanor in behavior; appearance; and
oral, written, and electronic communication.
NA 1 2 3 4 5
NA 1 2 3 4 5
4. Use technology ethically and appropriately to facilitate practice
outcomes
NA 1 2 3 4 5
NA 1 2 3 4 5
5. Use supervision and consultation to guide professional judgment
and behavior
NA 1 2 3 4 5
NA 1 2 3 4 5
End of First
Semester Rating
(SW 591)
End of Second
Semester Rating
(SW 592)
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
1.
2.
Make ethical decisions by applying the standards of the NASW Code of
Ethics, relevant laws & regulations, models of ethical decision-making,
ethical conduct of research, and additional codes of ethics as appropriate
to context.
Use reflection and self-regulation to manage persona values and maintain
professionalism in practice situations.
Comments: (rating 1 to 5):
Competency 2: Engage Diversity and Difference in
Practice
1.
2.
3.
Apply and communicate understanding of the importance of diversity and
difference in shaping life experiences in practice at the micro, mezzo and
macro levels.
Present as learners and engage clients and constituencies as experts of
their own experiences
Apply self-awareness and self-regulation to manage the influence of
personal biases and values in working with diverse clients and
constituencies.
Comments: (rating 1 to 5):
Competency 3: Advance Human Rights and Social,
Economic, and Environmental Justice
End of First
Semester Rating
(SW 591)
End of Second
Semester Rating
(SW 592)
1.
Apply understanding of social, economic, and environmental justice to
advocate for human rights at the individual and system levels.
NA 1 2 3 4 5
NA 1 2 3 4 5
2.
Engage in practices that advance social, economic, and environmental
justice.
NA 1 2 3 4 5
NA 1 2 3 4 5
End of First
Semester Rating
(SW 591)
End of Second
Semester Rating
(SW 592)
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
End of First
Semester Rating
(SW 591)
End of Second
Semester Rating
(SW 592)
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
Comments (rating 1 to 5):
Competency 4:Engage in Practice0informed Research and
Research-informed Practice
1.
Use practice experience and theory to inform scientific inquiry and
research.
1.
Apply critical thinking to engage in analysis of quantitative and
qualitative research methods and research findings
2.
Use and translate research evidence to inform and improve practice,
policy, and service delivery.
Comments (rating 1 to 5):
Competency 5: Engage in Policy Practice
1.
Identify social policy at the local, state, and federal level that impacts
well-being, service delivery, and access to social services.
2.
Assess how social welfare and economic policies impact the delivery of
and access to social services.
tocritical
social services
3. access
Apply
thinking to analyze, formulate, and advocate for policies
that advance human rights and social, economic and environmental
justice.
Comments (rating 1 to 5):
Competency 6: Engage with Individuals, Families,
Groups, Organizations, and Communities
1.
2.
Apply knowledge of human behavior and the social environment, personin-environment, and other multidisciplinary theoretical frameworks to
engage
with clients
and constituencies.
Use
empathy,
reflection,
and interpersonal skills to effectively engage
diverse clients and constituencies.
End of First
Semester Rating
(SW 591)
End of Second
Semester Rating
(SW 592)
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
End of First
Semester Rating
(SW 591)
End of Second
Semester Rating
(SW 592)
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
End of First
Semester Rating
(SW 521)
End of Second
Semester Rating
(SW 592)
Comments (rating 1 to 5):
Competency 7: Assess Individuals, Families, Groups,
Organizations, and Communities
1.
Collect and organize data, and apply critical thinking to
interpret information from clients and constituencies
2.
Apply knowledge of human behavior and the social environment, personin-environment, and other multidisciplinary theoretical frameworks in the
analysis of assessment data from clients and constituencies.
Develop mutually agreed-on intervention goals and objectives based on
the critical assessment of strengths, needs, and challenges within clients
and constituencies.
Select appropriate intervention strategies based on the assessment,
research knowledge, and values and preferences of clients and
constituencies.
3.
4.
Comments: (ratings 1 to 5):
Competency 8: Intervene with Individuals, Families, Groups,
Organizations, and Communities
1.
Critically choose and implement interventions to achieve practice goals
and enhance capacities of clients and constituencies.
NA 1 2 3 4 5
NA 1 2 3 4 5
2.
Apply knowledge of human behavior and the social environment, personin-environment, and other multidisciplinary theoretical frameworks in
interventions with clients and constituencies.
NA 1 2 3 4 5
NA 1 2 3 4 5
3.
Use inter-professional collaboration as appropriate to achieve beneficial
practice outcomes
NA 1 2 3 4 5
NA 1 2 3 4 5
4.
Negotiate, mediate, and advocate with and on behalf of diverse clients
and constituencies
NA 1 2 3 4 5
NA 1 2 3 4 5
5.
Facilitate effective transitions and endings that advance mutually agreedon goals.
NA 1 2 3 4 5
NA 1 2 3 4 5
End of First
Semester Rating
( SW 591)
End of Second
Semester Rating
(SW 592)
NA 1 2 3 4 5
NA 1 2 3 4 5
Comments: (ratings 1 to 5):
Competency 9: Evaluate Practice with Individuals, Families,
Groups, Organizations, and Communities
1.
Select and use appropriate methods for evaluation of outcomes
2.
Apply knowledge of human behavior and the social environment, personin-environment, and other multidisciplinary theoretical frameworks in the
evaluation of outcomes
NA 1 2 3 4 5
NA 1 2 3 4 5
3.
Critically analyze, monitor, and evaluate intervention and program
processes and outcomes
NA 1 2 3 4 5
NA 1 2 3 4 5
4.
Apply evaluation findings to improve practice effectiveness at the micro,
mezzo, and macro levels
NA 1 2 3 4 5
NA 1 2 3 4 5
Comments: (ratings 1 to 5):
Student Comments Regarding Evaluation and Field Experience for SW 591
Hours Completed:
Summary of Strengths/Weaknesses at End of SW 591:
Student Signature: ____________________ Date______
******************************************************************************************
Student Comments Regarding Evaluation and Field Experience for SW 592:
Hours Completed:________________
Summary of Strengths/Weaknesses at End of SW 592:
Student Signature: _____________________ Date ______