__________________________________________________________________________
Department of Social Work College of Health and Human Services
Field Education
749 Chestnut Street
Terre Haute, Indiana 47809
Telephone: 812-237-2322
Fax: 812-237-8114
MSW GENERALIST Field Placement: Learning Plan and Performance Evaluation
Name of Intern __________________________________ 991____________________
Generalist Level Placement SOWK 605 (Summer)

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 journal; 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 her/his 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 items listed may be used (highlighted), or the student or supervisor may individualize activities that meet the criteria (it should be added to the list). Selected items will be marked on this document. These items should be selected and marked 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. The only exception is that items in red and bold must be completed by each student.
The student should be evaluated at the midterm 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.

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
Evidence of
Completion: 1.
Practice Behavior Assignment Item 2. Verified by 3. Date
Complete
PB. 1
Advocate for client access to services of social work.
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:
PB. 2
Practice personal reflection and selfcorrection to assure continual professional development.
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

Practice Behavior Assignment
PB. 3
Attend to professional roles and boundaries.
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
PB. 4
Demonstrate professional demeanor in behavior, appearance, and communication.
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:
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete

Practice Behavior Assignment
PB. 5
Engage in Career learning.
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
PB. 6
Use supervision and consultation.
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:
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete

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.
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
PB. 8
Make ethical decisions by applying standards of the National
Association of Social
Workers Code of
Ethics.
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:
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete

Practice Behavior Assignment
PB. 9
Tolerate ambiguity in resolving ethical conflicts.
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
PB. 10
Apply strategies of ethical reasoning to arrive at principled decisions.
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:
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete

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.
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
PB. 12
Analyze models of assessment, prevention, intervention, and evaluation.
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:
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete

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.
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.
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
PB. 15
Gain sufficient selfawareness to eliminate the influence of personal biases and values in working with diverse groups.
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
PB. 16
Recognize and communicate their understanding of the importance of difference in shaping life experiences.
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:
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete

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.
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
Evidence of
Completion: 1.
Practice Behavior Assignment Item 2. Verified by 3. Date
Complete
PB. 18
Understand the forms and mechanisms of oppression and discrimination.
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
PB. 19
Advocate for human rights and social and economic justice.
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
PB. 20
Engage in practices that advance social and economic justice.
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:
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete

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.
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
PB. 22
Use research evidence to inform practice.
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:
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete

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
Evidence of
Practice Behavior Assignment
Completion: 1.
Item 2. Verified by 3. Date
Complete
PB. 23
Utilize conceptual frameworks to guide the processes of assessment, intervention, and evaluation.
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
PB. 24
Critique and apply knowledge to understand person and environment.
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:
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete

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
Evidence of
Practice Behavior Assignment
Completion: 1.
Item 2. Verified by 3. Date
Complete
PB. 25
Analyze, formulate, and advocate for policies that advance social well-being.
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
PB. 26
Collaborate with colleagues and clients for effective policy action.
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:
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete

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
Evidence of
Practice Behavior Assignment
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.
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
PB. 28
Provide leadership in promoting sustainable changes in service delivery and practice to improve the quality of social services.
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:
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete

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.
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
PB. 30
Use empathy and other interpersonal skills.
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:
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete

Practice Behavior Assignment
PB. 31
Develop a mutually agreed-on focus of work and desired outcomes.
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
PB. 32 Collect, organize, and interpret client data.
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:
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete

Practice Behavior Assignment
PB. 33
Assess client strengths and limitations.
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
PB. 34
Develop mutually agreed-on intervention goals and objectives.
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:
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete

Practice Behavior Assignment
PB. 35
Select appropriate intervention strategies.
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
PB. 36
Initiate actions to achieve organizational goals.
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:
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete

Practice Behavior Assignment
PB. 37
Implement prevention interventions that enhance client capacities.
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
PB. 38
Help clients resolve problems.
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:
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete

Practice Behavior Assignment
PB. 39
Negotiate, mediate, and advocate for clients.
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
PB. 40
Facilitate transitions and endings.
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:
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete

D: Evaluation. Social Workers
Practice Behavior Assignment
PB. 41
Critically analyze, monitor, and evaluate interventions.
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:
Evidence of
Completion: 1.
Item 2. Verified by
3. Date Complete

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, Date
The student has completed the above activities either under my supervision, or my designee, within the agency.
__________________________________________________________________________
Task/Agency Supervisor, 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, 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 excelling in field placement by performing above expectations for interns.


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 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; 5/2014; 08/2015