Concentration 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 593 □
SW 594 □
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 593)
1. Make ethical decisions by applying the standards of the NASW
NA 1 2 3 4 5
Code of Ethics, relevant laws & regulations, models of ethical
decision-making, ethical conduct of research, and additional codes
of ethics as appropriate to context.
End of Second
Semester Rating
(SW 594)
NA 1 2 3 4 5
2. Use reflection and self-regulation to manage persona values and
maintain professionalism in practice situations.
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
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
NA 1 2 3 4 5
5. Use supervision and consultation to guide professional judgment
and behavior
6. Demonstrate the ability to offer, accept, and respond to feedback
from other professionals in social work settings and in
interdisciplinary settings
7. Recognize the importance of, and demonstrate the capacity for,
NA 1 2 3 4 5
self-care in the agency context in order to facilitate personal social
work practice efficacy and individual well-being throughout their
careers
NA 1 2 3 4 5
Comments: (rating 1 to 5):
Competency 2: Engage Diversity and Difference in
Practice
End of First
Semester Rating
(SW 593)
1. Apply and communicate understanding of the importance of
NA 1 2 3 4 5
diversity and difference in shaping life experiences in practice at
the micro, mezzo and macro levels.
2. Present as learners and engage clients and constituencies as experts
of their own experiences
3. Apply self-awareness and self-regulation to manage the influence
of personal biases and values in working with diverse clients and
constituencies.
4. Identify and understand the ways in which individuals from
different ethnic, gender, racial, cultural, sexual identity and
orientation, and socioeconomic backgrounds and with different
abilities require different methods of engagement.
5. Adapt interventions in culturally responsive ways that show
recognition of issues of intersectionality at the micro, mezzo, and
macro levels
Comments: (rating 1 to 5):
End of Second
Semester Rating
(SW 594)
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
NA 1 2 3 4 5
Competency 3: Advance Human Rights and Social,
Economic, and Environmental Justice
1. Apply understanding of social, economic, and environmental
justice to advocate for human rights at the individual and system
levels.
2. Engage in practices that advance social, economic, and
environmental justice.
3. Assess how issues of privilege, social injustice, and inequities in
access to services and resources affect client difficulties and
therapeutic alliances across the micro, mezzo, and macro levels
4. Utilize an integrative, anti-oppressive perspective to promote
equitable access to services and resources for vulnerable groups
End of First
Semester Rating
(SW 593)
End of Second
Semester Rating
(SW 594)
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
Comments (rating 1 to 5):
Competency 4:Engage in Practice0informed Research and
Research-informed Practice
End of First
Semester Rating
(SW 593)
1. Use practice experience and theory to inform scientific inquiry and
NA 1 2 3 4 5
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.
End of Second
Semester Rating
(SW 594)
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
3. Adapt and modify research methodology to the social work setting,
NA 1 2 3 4 5 NA 1 2 3 4 5
with consideration for changes in the client’s concerns and in the
environment
4. Conduct practice in a recursive manner that includes constant
assessment while implementing interventions in social work
settings
Comments (rating 1 to 5):
NA 1 2 3 4 5 NA 1 2 3 4 5
Competency 5: Engage in Policy Practice
End of First
Semester Rating
(SW 593)
End of Second
Semester Rating
(SW 594)
1. Identify social policy at the local, state, and federal level that
NA 1 2 3 4 5
impacts well-being, service delivery, and access to social services.
NA 1 2 3 4 5
2. Assess how social welfare and economic policies impact the
delivery of and access to social services.
NA 1 2 3 4 5
NA 1 2 3 4 5
3. Apply critical thinking to analyze, formulate, and advocate for
policies that advance human rights and social, economic and
environmental justice.
NA 1 2 3 4 5
NA 1 2 3 4 5
4. Demonstrate knowledge of the ways in which agency dynamics
and larger systemic and environmental factors may impact issue
resolution, both positively and negatively
5. Identify avenues for intervention in the policy-making process in
order to advocate for clients and constituencies at all levels of
service delivery
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 6: Engage with Individuals, Families,
Groups, Organizations, and Communities
1. Apply knowledge of human behavior and the social environment,
person-in-environment, and other multidisciplinary theoretical
frameworks to engage with clients and constituencies.
2. Use empathy, reflection, and interpersonal skills to effectively
engage diverse clients and constituencies.
3. Apply a trauma-informed care perspective when working with
clients, colleagues and constituencies in order to facilitate
appropriate recognition of and response to the experiences and
effects of trauma at the micro, mezzo, and macro levels.
4. Use the client-social worker relationship and other professional
connections to facilitate attainment of client goals
Comments (rating 1 to 5):
End of First
Semester Rating
(SW 593)
End of Second
Semester Rating
(SW 594)
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
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,
person-in-environment, and other multidisciplinary theoretical
frameworks in the analysis of assessment data from clients and
constituencies.
End of First
Semester Rating
(SW 593)
End of Second
Semester Rating
(SW 594)
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. Develop mutually agreed-on intervention goals and objectives
NA 1 2 3 4 5
based on the critical assessment of strengths, needs, and challenges
within clients and constituencies.
4. Select appropriate intervention strategies based on the assessment,
NA 1 2 3 4 5
research knowledge, and values and preferences of clients and
constituencies.
NA 1 2 3 4 5
NA 1 2 3 4 5
5. Identify, evaluate, select, adopt, and modify assessment tools,
NA 1 2 3 4 5 NA 1 2 3 4 5
methods, and approaches in advanced practice with consideration
for the needs, backgrounds, and social characteristics of clients and
constituencies
6. Demonstrate the ability to develop and explain a comprehensive
assessment with consideration of theoretical models, practice
experiences, and research findings
NA 1 2 3 4 5 NA 1 2 3 4 5
Comments: (ratings 1 to 5):
Competency 8: Intervene with Individuals, Families, Groups,
Organizations, and Communities
End of First
Semester Rating
(SW 523)
End of Second
Semester Rating
(SW 594)
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
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
agreed-on goals.
NA 1 2 3 4 5
NA 1 2 3 4 5
1. Critically choose and implement interventions to achieve practice
goals and enhance capacities of clients and constituencies.
2. Apply knowledge of human behavior and the social environment,
person-in-environment, and other multidisciplinary theoretical
frameworks in interventions with clients and constituencies.
3. Use inter-professional collaboration as appropriate to achieve
beneficial practice outcomes
6. Demonstrate ability to critically assess and apply appropriate
models of practice in response to clients’ unique circumstances
and needs
NA 1 2 3 4 5 NA 1 2 3 4 5
7. Design an intervention strategy based upon assessment data at
multiple system levels
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
End of First
Semester Rating
( SW 593)
End of Second
Semester Rating
(SW 594)
NA 1 2 3 4 5
NA 1 2 3 4 5
2. Apply knowledge of human behavior and the social environment,
NA 1 2 3 4 5
person-in-environment, and other multidisciplinary theoretical
frameworks in the evaluation of outcomes
3. Critically analyze, monitor, and evaluate intervention and program
NA 1 2 3 4 5
processes and outcomes
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
NA 1 2 3 4 5
NA 1 2 3 4 5
5. Use appropriate tools and technology ethically to facilitate
NA 1 2 3 4 5 NA 1 2 3 4 5
accurate data management, both in the evaluation of ongoing work
and in the evaluation of outcomes of work
6. Use self-reflection and supervision to regularly evaluate and, if
necessary, modify practice
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 593
Hours Completed:
Summary of Strengths/Weaknesses at End of SW 593:
Student Signature: ____________________ Date______
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Student Comments Regarding Evaluation and Field Experience for SW 594:
Hours Completed:________________
Summary of Strengths/Weaknesses at End of SW 594:
Student Signature: _____________________ Date ______