____________________________________________________________________________
College of Health and Human Services
Department of Social Work
Field Education
749 Chestnut Street
Terre Haute, Indiana 47809
Telephone: 812-237-2322
Fax: 812-237-8114
BSW Student Field Placement: Learning Plan and Performance Evaluation
Name of Intern __________________________________
Level of Placement:
Senior 498(Fall) 
Senior 499(Spring)
Junior 480(Spring)
991____________________
Type of Evaluation:
Midterm 
Final

Name of Agency: _________________________________________________________
Name of Supervisor: ______________________________________________________
Name of Field Instructor: __________________________________________________
Date Evaluation was Completed __________________________
This evaluation is intended to give the intern feedback about her or his performance. The Faculty Field
Liaison (course instructor) has responsibility of assigning the grade for field instruction. The grade that is
assigned will be based on: the Faculty Field Liaison or Field Director’s overall evaluation of the student’s
performance in field placement in conjunction with the field instructor and task supervisor evaluation and
other submitted materials such as: intern journals; seminar participation; papers that integrate field with
classroom instruction.
The paper document of the evaluation form in the Field Manual Appendix serves as an aid in discussion
and understanding field documentation. For implementation of the document, students are required to use
the form electronically in Wiki in the course Blackboard site and do concurrent documentation on the
Wiki. Students should print from the Wiki and provide the document to each supervisor for midterm and
final evaluations, then once complete, the comments and ratings should be typed into the Wiki document
for future reference and usage. It is not an acceptable practice for the student to utilize a word document
on his/her own computer only; it must be documented in the Wiki in Blackboard.
Rating the Student:
10 The student is fully prepared to be an entry level social worker and demonstrates mastery of skill. The
student qualifies as ‘a shining star’. The student initiates action and has the ability to deal with the more
difficult aspects of this practice behavior and uses best practices in approaching situations. The student is
not afraid to use his/her abilities and does not hide from clients. The student no longer needs the
supervisor to prompt action and demonstrates a ‘can do’ attitude. Supervisor would like to have the
student as a colleague based on the student’s demonstration of skills and abilities.
9 The student demonstrates near mastery of skill. The student is mostly proficient though sometimes
does not show ‘best practice of all the necessary parts”. The student has an appropriate level of skills and
acts appropriately as situations arise most of the time. The student demonstrates best practice ‘more than
80% of the time”. The student is nearly ready to practice as a beginning level social worker without
supervision.
8 The student has an above average ability to perform as a social worker. The student demonstrates a
good grasp of skills and abilities and is capable and confident. The student has basic skills but still needs
experience and practice to establish best practice. Student asks for opportunities to gain the needed
practice by asking “Can I?” The student is clearly past the point of asking questions to learn the skills, but
more asking for the opportunity to practice the skills and abilities that she/he already has developed. The
role of the supervisor with this student decreased to occasional suggestion but more monitoring.
7 The student is meeting the expectations of social work practice, but the student still tends to ‘answer
the questions when asked’, rather than demonstrate independence, initiative and confidence. The student
has basic competence, and performs to the level of the average social worker, but has lacking ability to
perform best practices most of the time. The student is less likely to act without being prompted in a
situation and needs supervision and guidance by the supervisor to assure completion of tasks. Student is
now using intervention and evaluation skills though still needs continued practice to develop the skills.
6 The student is developing skills. The student is able to engage with clients and has an understanding
of the goals of the profession. The student is developing the ability to make decisions as situations occur
but still clearly is not ready to make decisions independently and needs to consult with supervisor before
taking actions with clients. In some settings, supervisors might allow the student to be alone with clients
or to co-facilitate a group. The student is able to demonstrate techniques and address some difficult
situations. The student is likely practicing boundary setting and/or the ability to sustain an engagement
with a client and is also able to USE resources.
5 The student is emerging. The student may be able to address very basic issues with a client in a
conversational manner, but is likely more focused on learning necessary knowledge and observation of
professionals in skill usage. The student is learning and experimenting with core knowledge as well as
engagement and assessment. The student has a moderate knowledge of resources and is beginning to
understand and use the resources.
4 The student is at the introductory, or beginning, level. The student has little experience or knowledge
of social agencies yet is inquisitive and curious, and demonstrates an awareness of surroundings. The
student is expected to begin to build core knowledge necessary to function within the agency and working
with clients by reviewing policies and procedures, learning forms and asking questions about their use,
and beginning to ask relevant questions about their ‘place’ and their role in the agency. Student is
learning resources that may be useful in serving the clients of the agency.
3 The student demonstrates less than motivated behavior and there is concern for the student’s
development. The student might be demonstrating resistance to working in some aspect of the agency or
with some types of clients, is not inquisitive or demonstrating inquiry and has difficulty ‘fitting in’. Staff
may be reporting not feeling that the student is ‘getting it’ or is demonstrating a lack of empathy or
compassion with clients.
2 The student is resistant to development and is not demonstrating a grasp of content. The student’s
manner and presentation are having a negative effect on the work environment and with clients.
Supervisors feels that the student is not ready to work with clients and needs to have some corrective
plans before being ready to move on in placement. Student is likely to be withdrawn from at least some
aspects of the placement due to inappropriateness. Outlook for the student is guarded and unless there are
significant changes the student is should not progress in the program.
1 Student demonstrates unacceptable behavior that has been addressed without successful change.
Further attempt to resolve presenting problems is not likely to make a difference. Student should be
removed from the field practicum.
0 Insufficient evidence to evaluate the student due to lack of opportunity in this setting, lack of
opportunity to see the student practice in the setting, or other reasonable factors limiting the evaluator’s
ability to rate.
Instructions for completing the document:
The student and Field Instructor/Task Supervisor will discuss learning plan goals and who will supervise
each activity. Together they will define at least 2 activities per practice behavior. The supplemental list
of assignments may be used, or the student or supervisor may individualize activities that meet the criteria.
Required items (those bolded and in red) must be completed by all students. Selected items will be
identified on this document within the first 2 weeks of placement. Any items designated for completion
with a Field Instructor outside the agency must also be marked as such, discussed with the Field
Instructor, and approved by all. In the case of a Field Instructor that is not an agency employee, the
student must maintain an open and transparent communication process with both supervisors throughout
the placement regarding all activities, hours, concerns, changes, etc.
Once an activity is completed the student should review the assignment with the designated supervisor and
note comments and completion date in the appropriate column of the document. The date should match
with journal entries and timesheets. Remember, concurrent documentation is an agency as well as field
practice.
The student should begin immediately to complete learning plan items, and should make progress weekly.
It is not acceptable to wait until end of placement to complete items.
N/A, ongoing, discussed, per supervisor, or blank are not acceptable replies to any learning plan item.
Every student should complete 2 items per placement; students may not repeat assignments in different
placements. The only exception is that items in red and bold must be completed by each student in each
placement.
The student should be evaluated at the mid-term and final by all parties involved in supervising the
student. In other words, if the student has one supervisor then only one evaluation is needed, but if the
student has more than one supervisor, they should each complete an evaluation of the student or jointly
complete one evaluation and both parties should sign.
Grey shaded practice behaviors are not required for junior (SOWK 480) students, but may be selected by
the student if so chosen. Senior BSW students must complete all assignments for all practice behaviors.
Competency 1: Identify as a professional social worker and conduct oneself accordingly. Social workers serve as
representatives of the profession, its mission, and its core values. They know the profession’s history. Social
workers commit themselves to the profession’s enhancement and to their own professional conduct and growth.
Social workers
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
PB. 1
Advocate for client access
to services of social work.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 2
Practice personal
reflection and selfcorrection to assure
continual professional
development.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 3
Attend to professional
roles and boundaries.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 4
Demonstrate
professional demeanor
in behavior,
appearance, and
communication.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 5
Engage in Career
learning.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Final 10 9 8 7 6 5 4 3 2 1 0
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 6
Use supervision and
consultation.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Competency 2: Apply social work ethical principles to guide professional practice. Social workers have
an obligation to conduct themselves ethically and to engage in ethical decision making. Social workers
are knowledgeable about the value base of the profession, its ethical standards, and relevant law.
Social workers
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
PB. 7
Recognize and manage
personal values in a way
that allows professional
values to guide practice.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 8
Make ethical decisions
by applying standards
of the National
Association of Social
Workers Code of
Ethics.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 9
Tolerate ambiguity in
resolving ethical
conflicts.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 10
Apply strategies of
ethical reasoning to
arrive at principled
decisions.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Competency 3: Apply critical thinking to inform and communicate professional judgments. Social
workers are knowledgeable about the principles of logic, scientific inquiry, and reasoned discernment.
They use critical thinking augmented by creativity and curiosity. Critical thinking also requires the
synthesis and communication of relevant information. Social workers
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
PB. 11
Distinguish, appraise, and
integrate multiple sources
of knowledge, including
research-based knowledge
and practice wisdom.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 12
Analyze models of
assessment,
prevention,
intervention, and
evaluation.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 13
Demonstrate effective
oral and written
communication in
working with
individuals, families,
organizations,
communities, and
colleagues.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Competency 4: Engage diversity and difference in practice. Social workers understand how diversity characterizes
and shapes the human experience and is critical to the formation of identity. The dimensions of diversity are
understood as the intersectionality of multiple factors including age, class, color, culture, disability, ethnicity,
gender, gender identity and expression, immigration status, political ideology, race, religion, sex, and sexual
orientation. Social workers appreciate that, as a consequence of difference, a person’s life experiences may
include oppression, poverty, marginalization, and alienation as well as privilege, power, and acclaim. Social
workers
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
PB. 14
Recognize the extent to
which a culture’s
structures and values may
oppress, marginalize,
alienate, or create or
enhance privilege and
power.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 15
Gain sufficient selfawareness to eliminate
the influence of
personal biases and
values in working with
diverse groups.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 16
Recognize and
communicate their
understanding of the
importance of
difference in shaping
life experiences.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 17
View themselves as
learners and engage
those with whom they
work as informants.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Competency 5: Advance human rights and social and economic justice. 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. Social workers recognize the global interconnections of oppression and are knowledgeable about
theories of justice and strategies to promote human and civil rights. Social work incorporates social justice
practices in organizations, institutions, and society to ensure that these basic human rights are distributed
equitably and without prejudice. Social workers
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
PB. 18
Understand the forms and
mechanisms of oppression
and discrimination.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 19
Advocate for human
rights and social and
economic justice.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 20
Engage in practices
that advance social and
economic justice.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Competency 6: Engage in research-informed practice and practice-informed research. Social workers
use practice experience to inform research, employ evidence-based interventions, evaluate their own
practice, and use research findings to improve practice, policy, and social service delivery. Social
workers comprehend quantitative and qualitative research and understand scientific and ethical
approaches to building knowledge. Social workers
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
PB. 21
Use practice to inform
scientific inquiry.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 22
Use research evidence
to inform practice.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Competency 7: Apply knowledge of human behavior and the social environment. Social workers are
knowledgeable about human behavior across the life course; the range of social systems in which
people live; and the ways social systems promote or deter people in maintaining or achieving health
and well-being. Social workers apply theories and knowledge from the liberal arts to understand
biological, social, cultural, psychological, and spiritual development. Social workers
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
PB. 23
Utilize conceptual
frameworks to guide the
processes of assessment,
intervention, and
evaluation.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 24
Critique and apply
knowledge to
understand person and
environment.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Competency 8: Engage in policy practice to advance social and economic well-being and to deliver
effective social work services. Social work practitioners understand that policy affects service delivery,
and they actively engage in policy practice. Social workers know the history and current structures of
social policies and services; the role of policy in service delivery; and the role of practice in policy
development. Social workers
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
PB. 25
Analyze, formulate, and
advocate for policies that
advance social well-being.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 26
Collaborate with
colleagues and clients
for effective policy
action.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Competency 9: Respond to contexts that shape practice. Social workers are informed, resourceful, and
proactive in responding to evolving organizational, community, and societal contexts at all levels of
practice. Social workers recognize that the context of practice is dynamic, and use knowledge and skill
to respond proactively. Social workers
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
PB. 27
Continuously discover,
appraise and attend to
changing locales,
populations, scientific and
technological
developments, and
emerging societal trends
to provide relevant
services.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 28
Provide leadership in
promoting sustainable
changes in service
delivery and practice
to improve the quality
of social services.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Competency 10: Engage, assess, intervene, and evaluate with individuals, families, groups, organizations, and
communities. Professional practice involves the dynamic and interactive processes of engagement, assessment,
intervention, and evaluation at multiple levels. Social workers have the knowledge and skills to practice with
individuals, families, groups, organizations, and communities. Practice knowledge includes 7 identifying,
analyzing, and implementing evidence-based interventions designed to achieve client goals; using research and
technological advances; evaluating program outcomes and practice effectiveness; developing, analyzing,
advocating, and providing leadership for policies and services; and promoting social and economic justice.
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
PB. 29
Substantively and
affectively prepare for
action with individuals,
families, groups,
organizations, and
communities.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 30
Use empathy and other
interpersonal skills.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 31
Develop a mutually
agreed-on focus of
work and desired
outcomes.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
B: Assessment. Social Workers
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 32 Collect, organize,
and interpret client data.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 33
Assess client strengths
and limitations.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 34
Develop mutually
agreed-on intervention
goals and objectives.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 35
Select appropriate
intervention strategies.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
C: Intervention. Social Workers
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 36
Initiate actions to achieve
organizational goals.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 37
Implement prevention
interventions that
enhance client
capacities.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 38
Help clients resolve
problems.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 39
Negotiate, mediate,
and advocate for
clients.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 40
Facilitate transitions
and endings.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
D: Evaluation. Social Workers
Practice Behavior
Assignment
Evidence of
Completion: 1.
Item 2. Verified by 3.
Date Complete
PB. 41
Critically analyze,
monitor, and evaluate
interventions.
Fall Semester:
Midterm 10 9 8 7 6 5 4 3 2 1 0
Final 10 9 8 7 6 5 4 3 2 1 0
Spring Semester: Midterm 10 9 8 7 6 5 4 3 2 1 0
Comments:
Final 10 9 8 7 6 5 4 3 2 1 0
Comments:
I have completed all of the assignments, as described, and have demonstrated professional and ethical
behavior in doing so. I have completed all assignments under the supervision of my task/agency
supervisor and/or my field instructor.
Student Signature and Date
The student has completed the above activities either under my supervision, or my designee, within the
agency.
Task/Agency Supervisor Signature and Date
I serve as Field Instructor for the student, as a consulting social worker. The student and I met for an hour
per week, or the equivalent, for the duration of this placement and I consulted with the student in relevant
activities and processes from the social work perspective.
Field Instructor Signature and Date
***All parties should review the full document prior to signing the document, and if there are discrepancies
with notation, it should be documented.
Overall Evaluation at MIDTERM:
Please check one of the following at the midterm evaluation. At the final evaluation do NOT complete this
section.
 This intern is meeting the expectations of a field placement intern.
 This intern is functioning somewhat below the expectations of a field placement intern. There is a question
whether this intern will be ready for beginning level social work practice by the end of placement.
 This intern is functioning below the expectations of a field placement intern. There is considerable concern
that this intern will not be ready for beginning level social work practice by the end of placement. This
This intern is excelling in field placement by performing above expectations for interns.
 intern should perhaps be encouraged to pursue another major.
Comments/elaboration:
Strengths:
Limitations:
FINAL OVERALL EVALUATION:
The student successfully completed her/his learning plan
□ Yes
□ No (explain)
Please check one of the following at the final evaluation. At the midterm evaluation do NOT complete this
section.
 This intern has excelled in field placement by performing above expectations for interns. If an appropriate
position were open at this agency, for a beginning level social worker, this intern would be considered
among the top candidates for this position.
 This intern has met the expectations of the field placement. This intern is ready for beginning level social
work practice.
 This intern is not yet ready for beginning level social work practice.
 This intern is not yet ready for beginning level social work practice, and has demonstrated serious problems
in performance, and perhaps should be encouraged to pursue another major.
Comments/elaboration:
Strengths:
Limitations:
Signature of Task/Agency Supervisor ______________________________________________
Date _____________
Signature of Field Instructor (if different than above) ________________________________
Date ___________________________
The following section should be completed by the intern:
My agency supervisor and Field Director, or designee, have discussed this evaluation with me, and I have
received a copy. My agreement or disagreement follows:
I agree with the evaluation

or
I do not agree with evaluation

If the intern disagrees with the evaluation she/he should state that disagreement in writing and submit a copy
to both the agency supervisor and the Field Director.
Intern’s Signature _________________________________
Date _____________________
03/2001; Revised 11/14/2002; 07/2005; 08/2007; 08/2008; 08/2009; 08/2013; 8/2014; 8/2015