MSW Clinical Mid-Semester Student Evaluation
To be completed by the Student & Field Instructor prior to review by the Liaison.
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Student’s Name:
WIN Number:
Student Attended MSSE w/Liaison?
Yes
No
Agency/program:
Field Instructor:
Liaison/Seminar Instructor:
Date:
1. Field Instruction and Supervision
1.a Is one hour per week of individual supervision being provided,
as required by BSRB and Washburn University’s SW department?
Yes
No
1.b Is this adequate?
Yes
No
1.c Does the student attend a group supervision process in adjunct
to individual supervision?
Yes
No
1.e Are all cases assigned to the student discussed during
individual supervision time?
Yes
No
1.f Is student’s professional development discussed during individual
supervision time?
Yes
No
1.g Does student demonstrate adequate accessibility to field instructor
and agency (e.g. punctual, reliable)?
Yes
No
1.h Does student demonstrate preparation and readiness for supervision.
(e.g. bring list of questions pertaining to field)?
Yes
No
Yes
No
1.d If yes, what type of adjunct supervision is provided?
2. Supervisory Relationship
2.a Is student able to share successes, challenges, or concerns with
field instructor in open and direct ways?
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2.b Have there been any challenges within the supervisory process
and/or relationship?
2.c If yes, have the difficulties been resolved?
Identify solution focused method(s) used.
Yes
No
Yes
No
3. Service Populations (Indicate numbers of clients and/or groups assigned to student)
3.a Total number of individuals, children and
youth:
3.b Total number of individuals, adults:
3.e Total number of community groups:
3.f % of caseload who are in racial/ethnic
minority:
3.c Total number of families:
3.g Practicum hours:
3.d Total number of client groups:
4. Evaluate student’s progress in achieving Learning Contract objectives (50 words or less):
Competency Scoring Instructions
This part of the Evaluation Form is designed to allow the Field Instructor to give input to the Social
Work Department regarding the performance of the student practicum. Nine Core Competencies
are covered. For each question an ascending scoring scale is used in this evaluation where
0 
no proficiency. Student is unable to perform even minimal tasks and does not demonstrate an
understanding of the theoretical base of materials.
1 
minimal proficiency demonstrated under optimal conditions. Student requires intensive
supervision and/or redirection.
2 
marginal proficiency demonstrated under favorable conditions. Student demonstrates effort
but has difficulty meeting expectations.
3 
acceptable proficiency demonstrated under normal conditions OR no problems noted.
Student demonstrates both the ability and knowledge to meet expectations.
4 
above average proficiency demonstrated under normal conditions. Student demonstrates
acceptable proficiency under difficult conditions.
5 
exceptional proficiency. Student demonstrates above average proficiency under both
normal and difficult conditions
We encourage a collaborative process for completing this evaluation. One method is for the
student and field instructor to score the evaluation together as part of their mentoring experience.
1. Discuss the evaluation together, then complete the form. Comments can be included in any
section, as needed.
2. After the Student and Field Instructor sign and date the form, it can be given to the Student’s
Practicum Liaison who signs and dates it and gives it to the Practicum Director.
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Goal 1: Demonstrate ethical and professional behavior.
Learning Objectives
Learning Objective 1.A:
Make ethical decisions by
applying the standards of the
NASW Code of Ethics,
relevant laws and
regulations, models for
ethical decision-making,
ethical conduct of research,
and additional codes of
ethics as appropriate to
context
Learning Objective 1.B:
Use reflection and selfregulation to manage
personal values and
maintain professionalism in
practice situations
Learning Objective 1.C:
Demonstrate professional
demeanor in behavior;
appearance; and oral,
written, and electronic
communication
Rating (according to Competency Scoring
Instructions on page 2)
Click in the box next to your rating choice;
an “X” will appear.
Note: “3” = “satisfactory” or “no problems noted”
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
Comments
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Learning Objective 1.D:
Use technology ethically and
appropriately to facilitate
practice outcomes
Learning Objective 1.E:
Use supervision and
consultation to guide
professional judgment and
behavior
0
1
2
3
4
5
0
1
2
3
4
5
Goal 2: Engage diversity and difference in practice.
Learning Objectives
Learning Objective 2.A:
Apply and communicate
understanding of the
importance of diversity and
difference in shaping life
experiences in practice at the
micro, mezzo, and macro
levels
Rating (according to Competency Scoring
Instructions on page 2)
Click in the box next to your rating choice;
an “X” will appear.
Note: “3” = “satisfactory” or “no problems noted”
0
1
2
3
4
Comments
5
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Learning Objective 2.B:
Present themselves as
learners and engage clients
and constituencies as experts
of their own experiences
Learning Objective 2.C:
Apply self-awareness and
self-regulation to manage
the influence of personal
biases and values in working
with diverse clients and
constituencies
0
1
2
3
4
5
0
1
2
3
4
5
Goal 3: Advance human rights and social, economic, and environmental justice.
Learning Objectives
Learning Objective 3.A:
Apply their understanding of
social, economic, and
environmental justice to
advocate for human rights at
the individual and system
levels
Rating (according to Competency Scoring
Instructions on page 2)
Click in the box next to your rating choice;
an “X” will appear.
Note: “3” = “satisfactory” or “no problems noted”
0
1
2
3
4
Comments
5
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Learning Objective 3.B:
Engage in practices that
advance social, economic,
and environmental justice
0
1
2
3
4
5
Goal 4: Engage in practice-informed research and research-informed practice.
Learning Objectives
Learning Objective 4.A:
Use practice experience and
theory to inform scientific
inquiry and research
Learning Objective 4.B:
Apply critical thinking to
engage in analysis of
quantitative and qualitative
research methods and
research findings
Learning Objective 4.C:
Use and translate research
evidence to inform and
improve practice, policy, and
service delivery
Rating (according to Competency Scoring
Instructions on page 2)
Click in the box next to your rating choice;
an “X” will appear.
Note: “3” = “satisfactory” or “no problems noted”
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
Comments
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Goal 5: Engage in policy practice.
Learning Objectives
Learning Objective 5.A:
Identify social policy at the
local, state, and federal level
that impacts well-being,
service delivery, and access
to social services
Learning Objective 5.B:
Assess how social welfare
and economic policies
impact the delivery of and
access to social services
Learning Objective 5.C:
Apply critical thinking to
analyze, formulate, and
advocate for policies that
advance human rights and
social, economic, and
environmental justice
Rating (according to Competency Scoring
Instructions on page 2)
Click in the box next to your rating choice;
an “X” will appear.
Note: “3” = “satisfactory” or “no problems noted”
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
Comments
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Goal 6: Engage with individuals, families, groups, organizations, and communities.
Learning Objectives
Learning Objective 6.A:
Apply knowledge of human
behavior and the social
environment, person-inenvironment, and other
multidisciplinary theoretical
frameworks to engage with
clients and constituencies
Learning Objective 6.B:
Use empathy, reflection,
and interpersonal skills to
effectively engage diverse
clients and constituencies
Rating (according to Competency Scoring
Instructions on page 2)
Click in the box next to your rating choice;
an “X” will appear.
Note: “3” = “satisfactory” or “no problems noted”
0
1
2
3
4
5
0
1
2
3
4
5
Comments
Goal 7: – Assess individuals, families, groups, organizations, and communities.
Learning Objectives
Learning Objective 7.A:
Collect and organize data,
and apply critical thinking to
interpret information from
clients and constituencies
Rating (according to Competency Scoring
Instructions on page 2)
Click in the box next to your rating choice;
an “X” will appear.
Note: “3” = “satisfactory” or “no problems noted”
0
1
2
3
4
Comments
5
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Learning Objective 7.B:
Apply knowledge of human
behavior and the social
environment, person-inenvironment, and other
multidisciplinary theoretical
frameworks in the analysis
of assessment data from
clients and constituencies
Learning Objective 7.C:
Develop mutually agreed-on
intervention goals and
objectives based on the
critical assessment of
strengths, needs, and
challenges within clients
and constituencies
Learning Objective 7.D:
Select appropriate
intervention strategies
based on the assessment,
research knowledge, and
values and preferences of
clients and constituencies
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
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Goal 8: Intervene with individuals, families, groups, organizations, and communities.
Learning Objectives
Learning Objective 8.A:
Critically choose and
implement interventions to
achieve practice goals and
enhance capacities of
clients and constituencies
Rating (according to Competency Scoring
Instructions on page 2)
Click in the box next to your rating choice;
an “X” will appear.
Note: “3” = “satisfactory” or “no problems noted”
0
1
2
3
4
5
0
1
2
3
4
5
Learning Objective 8.C:
Use inter-professional
collaboration as appropriate
to achieve beneficial
practice outcomes
0
1
2
3
4
5
Learning Objective 8.D:
Negotiate, mediate, and
advocate with and on
behalf of diverse clients and
constituencies
0
1
2
3
4
5
Learning Objective 8.B:
Apply knowledge of human
behavior and the social
environment, person-inenvironment, and other
multidisciplinary theoretical
frameworks in interventions
with clients and constituencies
Comments
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Learning Objective 8.E:
Facilitate effective
transitions and endings that
advance mutually agreed-on
goals
0
1
2
3
4
5
Goal 9: Evaluate practice with individuals, families, groups, organizations, and communities.
Learning Objectives
Learning Objective 9.A:
Select and use appropriate
methods for evaluation of
outcomes
Learning Objective 9.B:
Apply knowledge of human
behavior and the social
environment, person-inenvironment, and other
multidisciplinary theoretical
frameworks in the
evaluation of outcomes
Learning Objective 9.C:
Critically analyze, monitor,
and evaluate intervention
and program processes and
outcomes
Rating (according to Competency Scoring
Instructions on page 2)
Click in the box next to your rating choice;
an “X” will appear.
Note: “3” = “satisfactory” or “no problems noted”
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
Comments
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Learning Objective 9.D:
Apply evaluation findings to
improve practice
effectiveness at the micro,
mezzo, and macro levels
0
1
2
3
4
5
ADDENDUM: CLINICAL EVALUATION
1. Work collaboratively
with the client to
clinically assess strengths
and vulnerabilities
2. Select, plan, implement
and evaluate clinical
ethical interventions
3. Select, plan, implement
and evaluate clinical
evidence-based
interventions
4. Select, plan, implement
and evaluate clinical
interventions in a
culturally competent
manner respecting
diversity and difference
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
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5. Accurately interprets and
synthesizes clinical
assessment data (in the
context of culture,
person-in-environment)
6. Engages in clinical selfawareness and selfevaluation leading to selfcorrection
7. Clinical decisions are
made consistent with
relevant laws,
regulations, and SW
ethical standards and
values
8. Seeks clinical
supervision and uses
feedback to improve
clinical performance
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
Student Signature ________________________________________ Date _____________
Field Instructor Signature ___________________________________Date _____________
Liaison Signature _________________________________________Date _____________
Director of Practicum Signature ______________________________Date _____________
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