S CHOOL OF E DUCATION
U
W
-S
F ALL 2013

Preface………………………………………………………………………………………………….….3
A. Practicum Prerequisites ………………………………………………………………………………4
B. Course Objectives ………….. ……………………………………………………………… .......... …4
C. Skill and Knowledge Competencies……… ……………………………………………………..4 - 5
D. Human Diversity and Underserved Populations……… .......................................................... …5
E. Practicum Placement………………………………………………………………………………5 - 6
F. Supervision…………………………………………………………………………………………..6 - 7
G. Documentation Requirements…………………………………………………………………….7 - 8
H. Evaluation……………………………………………………………………………………………8 - 9
Appendices
Appendix A: Data Sheet
Appendix B: Practicum Evaluation
Appendix C: Academic Intervention and Progress Monitoring Case Feedback Form
Appendix D: Functional Behavior Assessment and Intervention Case Feedback Form
Appendix E: General Consultation/Intervention Case Feedback Form
Appendix F: Practicum Site Checklist
Appendix G: Instructions/Example Practicum Plan
Appendix H: Practicum Plan
Appendix I: Student Evaluation of Practicum Site
Appendix J: Practicum Log Template
Appendix K: Practicum Activity Checklist (University Supervisor)
Practicum I School Psychology Manual Page 2

The University of Wisconsin-Stout (UW-Stout) School Psychology Program prepares practitioners in the field of school psychology. Within the context of the scientist-practitioner model, program goals are designed to train highly reflective professionals who provide effective school psychology services that result in direct, measurable, and positive impact on children, families, and schools .
UW-Stout’s School Psychology Program requires five applied experiences: four practica and an internship.
Candidates apply their knowledge and skills in relevant settings, under conditions of appropriate supervision and evaluation.
1) Field Practicum I in a school setting
2) Field Practicum II in a school setting
3) Clinical Practicum I at Stout Clinical Services Center
4) Clinical Practicum II at Stout Clinical Services Center
5) Internship in School Psychology
The practica and internship are similar in the following ways:
A.
Each experience requires candidates to meet skill and knowledge competencies from the National
Association of School Psychologist’s (NASP’s) 10 domains of professional practice.
B.
Each experience is consistent with the program goals (see School Psychology Student Handbook).
C.
Each experience emphasizes and values human diversity.
Each practica and internship are distinct in the following ways:
A.
Objectives
B.
Placement procedures
C.
Expectations of skill development and level of independence
D.
Course requirements
E.
Style/system of supervision
UW-Stout’s School Psychology Program assesses candidates’ professional competencies through a progressive model of skill development. As candidates move through practica and internship, their knowledge and skills are assessed by program faculty and qualified site supervisors along a continuum of performance-based stages.
Unestablished
Practicum I
Observer Novice
Practicum II
Advanced
Novice
Internship
Emerging
Practitioner
Established
Practitioner
Advanced
Practitioner
The system and style of supervision appropriately matches candidates’ skill progression and performance. During early applied experiences, as candidates develop skills at the observer and novice stages, supervision is tutorial in nature. During later applied experiences, as candidates progress into practitioner stages, supervision becomes highly consultative and the relationship between the supervisor and intern is that of a mentor and mentee.
UW-Stout’s School Psychology Program provides appropriate oversight to ensure placements provide a breadth of quality activities, which are integrated across the NASP Practice Model domains. Collaboration between the university and sites ensure candidates have diverse experiences, appropriate levels of supervision, and successfully achieve the diverse goals of the school psychology program.
Each practicum and internship has its own manual, which provides the policies, procedures, and requirements of the applied experience.
Practicum I School Psychology Manual Page 3

A.
Practicum Prerequisites
Candidates enroll in Practicum I when they have prepared to develop observer, novice, and advanced
novice competencies, demonstrated through successful completion of the following:
1.
Foundational First-Year Coursework
2.
Satisfactory Benchmark I Evaluation
3.
Satisfactory Disposition Ratings during the Spring Semester of Year I
B.
Practicum I Course Objectives
1.
Students will demonstrate novice to advanced novice level school psychology competencies, consistent with the NASP Practice Model. (See Skills and Knowledge Competencies below.)
2.
Students will define and analyze the varied roles of the school psychologist in the educational process.
3.
Students will identify and seek resources for professional development related to relevant topics in the field.
4.
Students will demonstrate effective professional communication and problem-solving skills.
5.
Students will engage in and demonstrate collaborative relationships.
C.
Skill and Knowledge Competencies
The goal of Practicum I in School Psychology is to become a novice to advanced novice, who is reflective and integrates experiences across the range of NASP domains:
1.
Data-Based Decision Making and Accountability: School psychologists have knowledge of and skills in varied models and methods of assessment and data collection for identifying strengths and needs, developing effective services and programs, and measuring progress and outcomes.
2.
3.
Consultation and Collaboration: School psychologists have knowledge of and skills in varied models and strategies of consultation, collaboration, and communication applicable to individuals, families, groups, and systems and methods to promote effective implementation of services.
Interventions and Instructional Support to Develop Academic Skills: School psychologists have knowledge of biological, cultural, and social influences on academic skills; human learning, cognitive, and developmental processes; and skills in developing and implementing evidencebased curricula and instructional strategies.
4.
5.
6.
Interventions and Mental Health Services to Develop Social and Life Skills: School psychologists have knowledge of biological, cultural, developmental, and social influences on behavior and mental health, behavioral and emotional impacts on learning and life skills, and skills in developing and implementing evidence-based strategies to promote social–emotional functioning and mental health.
School-Wide Practices to Promote Learning: School psychologists have knowledge of school and systems structure, organization, and theory; general and special education; technology resources; and skills in developing and implementing evidence-based school practices that promote learning and mental health.
Preventive and Responsive Services: School psychologists have knowledge of principles and research related to resilience and risk factors in learning and mental health, skills in implementing
Practicum I School Psychology Manual Page 4

7.
8.
services in schools and communities to support multitiered prevention, and skills in implementing evidence-based strategies for effective crisis response.
Family–School Collaboration Services: School psychologists have knowledge of principles and research related to family systems, strengths, needs, and culture; skills in implementing evidencebased strategies to support family influences on children’s learning and mental health; and strategies to develop collaboration between families and schools.
Diversity in Development and Learning: School psychologists have knowledge of individual differences, abilities, disabilities, and other diverse student characteristics; principles and research related to diversity factors for children, families, and schools, including factors related to culture, context, and individual and role difference; and skills in implementing evidence-based strategies to enhance services and address potential influences related to diversity.
9.
Research and Program Evaluation: School psychologists have knowledge of and skills in research design, statistics, measurement, varied data collection and analysis techniques, and program evaluation sufficient for understanding research and interpreting data in applied settings.
10.
Legal, Ethical, and Professional Practice: School psychologists have knowledge of the history and foundations of school psychology; multiple service models and methods; ethical, legal, and professional standards; and other factors related to professional identity and effective practice as school psychologists.
D.
Human Diversity and Underserved Populations
The School Psychology Program at the University of Wisconsin-Stout is fully committed to instilling the value of multiculturalism and human diversity. The program encourages students to develop their knowledge and skills in best practices related to diverse and/or underserved populations, including language, race, disability status, religion, cultural background, and sexual orientation. This is accomplished by discussion of current research and practices related to diversity in areas such as assessment, diagnosis, consultation, and intervention, and is infused throughout course content.
Additionally, relevant focused objectives are embedded into practicum plans to allow students to gain applied experiences working with diverse and underserved populations, appropriate to their individual school settings.
E. Practicum I Placement
1. Hours and Timeline: UW-Stout’s Practicum I in School Psychology is a school-based applied experience, completed on a part-time basis over one half of the academic year. A total of 300 practicum hours are required per semester, for a total of 600 practicum hours across Practicum I and
Practicum II experiences.
Practicum I School Psychology Manual Page 5

2. Practicum Settings: Practicum settings are selected on the basis of evidence that the school/agency and field-based supervisor will include the following as practicum goals: a) knowledge of and commitment to high standards of professional responsibility consistent with NASP Codes of Ethics; b) evidence of sound and current assessment, intervention, and consultation skills as well as a willingness to explore better methods of practice and new psychological knowledge; and c) development of positive working relationships with the school, local, and wider professional community.
Practicum students are placed only with field-based supervisors who have been employed as a licensed and credentialed school psychologist for a minimum of three years.
3. Placement Guidelines: Practicum students are provided with a variety of experiences (see
Appendix F). Placements in field-based settings (local and state schools) are available. Depending on the individual needs of each student, their placements can be in various school settings (rural, suburbs, intercity) as well as with diverse populations.
4. University Responsibility
 UW-Stout School Psychology Program is responsible for providing direct oversight to the practicum experience to ensure appropriateness of placement.
 Open communication and collaboration between the university and sites ensure candidates have diverse experiences, appropriate levels of supervision, and successfully achieve the diverse goals of the school psychology program.
 The school psychology program will provide both information on practicum requirements and support for supervision to the student and supervisor.
 A university supervisor will monitor the progress of the student with the following: direct contact with the field supervisor at least twice per semester, direct contact with the students at least twice a month during seminar and individual meetings, and evaluating the student.
F. Supervision
1. Field Supervisor
 The field supervisor must hold a full state school psychologist’s license (or other appropriately credentialed psychologist in non-school settings), have three years of experience, and have had at least one year of experience in the school district (or agency) within which the school psychology student will be working (refer to university supervisor for alternatives if this last requirement is not feasible).
 The field supervisor/mentor shall be responsible for no more than one practicum student at any given time, unless the field supervisor/mentor has been assigned a significant portion of their time devoted to supervising practicum students.
 The field supervisor/mentor, with prompting from the student, will complete two evaluations— one towards the middle of the semester and one towards the end of the semester (see
Appendix B).
 In the event that a concern of a serious nature arises, the field supervisor/mentor is directed to contact the University supervisor, to discuss the matter in detail and formulate a plan. See
Evaluation section below for options of plan formulation.
Practicum I School Psychology Manual Page 6

2. University Supervisor
 The university supervisor is a program faculty or academic staff member teaching in the
School Psychology Program.
 University supervision is both informative and collaborative. Supervision involves the monthly seminar meetings and more frequent contact as requested by either the student or the supervisor.
 The university supervisor assesses the students progress through formative and summative evaluation, using course requirements and logs as artifacts (see below).
G. Documentation Requirements (refer to Learn@Stout for due dates)
These data are required and must be submitted each semester. Documentation needs to be submitted to the instructor (it is the student’s responsibility to make sure the instructor has this documentation, not the supervisor).
 Data Sheet: A data sheet with relevant contact information regarding the practicum site must be completed and turned into instructor by the beginning of the first seminar. If the assigned university supervisor is not the instructor, a copy needs to be provided to the supervisor (see
Appendix A).
 Practicum Plan: Students are to develop a practicum plan for the semester in collaboration with their field-based supervisor listing professional goals and objectives, as well as projects to be completed to meet the goals and objectives, and timelines for measuring outcomes of the practicum. The practicum plan must document activities in relation to the domains of competency as defined by the NASP Blueprint. The student, field-based supervisor and
university supervisor must sign the practicum plan. The original is turned into the instructor within the first two weeks of the semester. The student, field-based supervisor, and university supervisor should keep copies.
 Midterm Site Evaluation: Evaluation Guide for School Psychology: Practicum I (see Appendix
B) must be completed by the field-based supervisor and the practicum student at midsemester (refer to D2L for due dates).
 Practicum Log: Students must maintain a log of activities. Each semester, each student must participate in a minimum of 10 cases. Cases can involve evaluations/ assessments, consultation, and/or counseling individuals or groups. Three of the cases should be comprehensive assessments. In addition, students will arrange to conduct each of the following activities over the course of the year:
 Implement and monitor an academic intervention using CBMs
 Conduct a comprehensive social-emotional assessment
 Conduct a behavioral case consultation
 Conduct a Functional Behavior Analysis assessment (this may be the same case as the behavioral case consultation)
 Participate in 2 cases per semester involving student from a diverse population or circumstance.
 A complete psycho-educational report or write-up is required. In addition, students should use the attached Intervention/Consultation Feedback sheet (see Appendix E) to obtain feedback from the consultee with whom they worked. Students then submit logs to each
Practicum I School Psychology Manual Page 7

practicum seminar to be examined by the instructors.
 Practicum Summary: The practicum summary provides an opportunity for the student to summarize practicum experiences and activities. The student should review the practicum plan (see Appendix H) and practicum logs (see Appendix K) to determine if practicum goals were met and to plan for practicum or internship experiences to follow in the next semester.
 Case Study: Students will complete a minimum of one complete case study of evaluation/assessment (or counseling or consultation) per semester. The cases will be presented at the practicum meetings. The student will provide a one page handout summarizing information about the case to the instructors and the other students. A complete psycho-educational report or write-up of the case disposition is required at the end of the semester.
 End term Site Evaluation: The Evaluation Guide for School Psychology: Practicum II (see
Appendix B) must be completed by the field-based supervisor as well as the practicum student at the end of each semester.
Practicum Portfolio: Students will add to their portfolio during their practicum experience. As part of their practicum plan, students will address all eleven areas of the NASP Blueprint. By the end of the practicum experience, students should have a minimum of 3 artifacts that demonstrate skill or competency in each of the NASP professional domains. Portfolios are submitted at the end of
Practicum II (spring semester), however they should be attended throughout the year.
H. Evaluation
1.
Formative/Mid-Semester Performance-Based Evaluation
 Field Supervisor Evaluation: Towards the mid-point of the intern’s first semester of practicum, the field supervisor/mentor fills out the Practicum I Evaluation (see Appendix
B). Because the purpose of this tool is to provide formative feedback to the student, field supervisors/mentors should meet with the student personally to discuss the student’s performance. The students are then responsible for submitting these evaluations to the university supervisor.
 Student Self-Evaluation: At the mid-point of the semester, the student will complete a mid-semester/formative evaluation to assess the course objectives (see Appendix B).
Students include this evaluation as part of their formative evaluation discussion with their field based supervisor. The students are then responsible for submitting these to the university supervisor.
2.
Summative/Final Performance-Based Evaluation
 Field Supervisor Evaluation: Towards the end of the semester, the field supervisor again fills out the Practicum I Evaluation (see Appendix B). While the intent of this rating is summative, field supervisors are still encouraged to meet with the student about his/her performance. The students are then responsible for submitting these evaluations to the university supervisor.
 Student Self-Evaluation: Towards the end of the semester, the student will complete a
Practicum I School Psychology Manual Page 8

summative/final evaluation to assess the course objectives (see Appendix B). Students include this evaluation as part of their formative evaluation discussion with their field based supervisor. The students are then responsible for submitting these to the university supervisor.
3. Serious Performance Issues
 The practicum placement has a right to expect appropriate conduct and learning experiences from the student, within the framework of appropriate supervision and support. In the event that a concern of a serious nature arises, the field supervisor is directed to contact the University supervisor, to discuss the matter in detail and formulate a plan that may include the following:
 A) a three-way meeting with student to discuss the issue of concern and develop an informal plan to address or remediate the issue, B) a three-way meeting with the student to discuss the issue of concerns and develop a formal remediation plan, C) suspension or termination of the student from the practicum setting.
4.
Minimum Performance Expectations
Successful completion of Practicum I requires all of the following:
 80% of ratings at the Novice level, or higher, on the Summative/Final Site Evaluation
(appendix E)
 Evidence of completion of a minimum of 1 cases involving an academic and behavioral interventions and a consultation (appendices C, D, E). (All three cases are required for scoring by the end of Practicum II.)
5.
Course Grades
 To receive a grade in this course, students must ensure all required paperwork has been submitted to the course instructor by the last practicum meeting of each semester.
Students will be evaluated on their practicum attendance, seminar meeting attendance, and case studies. Final course grades will be determined by overall competency, with a major emphasis on the practicum student’s ability to demonstrate effective school psychological service delivery, professional conduct, and ethical conduct. Course grades will be based on the following:


Evaluations by the field supervisor
Regular participation and attendance at seminars
 Professional and ethical conduct
 Responsibility in submitting all required paperwork/forms
30%
30%
20%
20%
Practicum I School Psychology Manual Page 9

Appendices
Practicum I School Psychology Manual Page 10

Appendix A
University of Wisconsin-Stout
Student:
ID:
Home Address:
(Last) (First)
Date
Home Phone:
Email:
School
Address:
Work Phone:
Field-based Supervisor:
Address:
Phone:
Email:
District Administrator:
Phone:
Email:
Return copies of this form to:
-----------------------------------------------------------------------------------------------------------------------------------------------------------
1) Tracy DeRusha, School of Education, 267 Home Economics, UW-Stout, Menomonie, WI 54751; and
2) The Practicum Seminar Instructor: Christine Peterson, 411 McCalmont Hall, UW-Stout, Menomonie, WI 54751 or FAX: 715-232-1400
Practicum I School Psychology Manual Page 11

Appendix B
Field Practicum I Evaluation
School Psychology
University of Wisconsin—Stout
Student Name: _________________________________________
School Site: ____________________________________________ Review Date: ________________
Field Supervisors Name: __________________________________
Directions:
Mid-Term Final
Self Eval Supervisor Eval
Using the following performance-based stages as a guide, please rate the student on each item.
Unestablished Observer Novice Advanced Novice
Skills and behaviors have not been demonstrated to the degree necessary for successful performance.
Student can observe and identify relevant activities and functions and discuss/report their experiences; demonstrating awareness and emerging knowledge of the profession. Additional training and supervision are expected.
Student demonstrates the skills and behaviors necessary to participate in and contribute to relevant activities and functions; building competence while continuing to receive substantial guidance and supervision.
NASP Domain 1: Data-Based Decision
Making and Accountability
Unestablished Observer Novice
Student demonstrates the skills and behaviors necessary to significantly participate in and substantially contribute to relevant activities and functions; continuing to build competence while requiring reduced levels of direct supervision. Continued indirect supervision is expected.
Advanced
Novice
Not Observed
1. Utilizes varied methods of assessment for identifying a comprehensive student profile of strengths and weaknesses (i.e., cognitive, academic, social-emotional, adaptive).
2. Identifies all aspects of the referral concern to be addressed by the assessment.
3. Accurately administers, scores, and interprets norm-referenced and curriculum-based measures.
4. Accurately conducts comprehensive functional behavioral assessments which lead to effective intervention plans.
5. Accurately collects and graphs data.
Practicum I School Psychology Manual Page 12

6. Completes reports that are precise, well-integrated, and understandable.
7. Uses data to measure outcomes of services as part of a comprehensive problem solving model.
NASP Domain 1 meets WI Department of Public Instruction Pupil Service Standards 3
NASP Domain 2: Consultation and
Collaboration
Unestablished Observer Novice
1. Applies psychological and educational principles to achieve positive outcomes for children
(behavioral, problem-solving, mental health, organizational, instructional).
2. Effectively communicates and works collaboratively within a group/meeting setting (i.e., participates actively in and/or effectively leads group meetings.)
3. Facilitates a problem-solving process amongst parents and/or professionals for planning, implementing, and evaluating interventions.
NASP Domain 2 meets WI Department of Public Instruction Pupil Service Standard 5, 7
Unestablished Observer NASP Domain 3: Interventions and
Instructional Support to Develop
Academic Skills
Novice
1. Demonstrates knowledge of curriculum and instructional strategies that facilitate academic achievement
(ex., teacher-directed instruction, literacy instruction, peer-tutoring, interventions for self-regulation and planning/organization, etc).
2. Develops appropriate academic goals for children with diverse abilities, disabilities, backgrounds, strengths, and needs.
Practicum I School Psychology Manual
Advanced
Novice
Not Observed
Advanced
Novice
Not Observed
Page 13

3. Develops and implements (directly or via consultation) appropriate academic interventions that are linked to student needs.
4 . Evaluates effectiveness of academic interventions and makes appropriate changes based on empirical evidence.
NASP Domain 3 meets WI Department of Public Instruction Pupil Service Standards 2, 6
Unestablished Observer Novice NASP Domain 4: Interventions and
Mental Health Services to Develop Social
& Life Skills
1. Demonstrates knowledge of strategies in social-emotional, behavioral, and mental health services
(ex., counseling, behavioral intervention, social skills interventions, instruction for selfmonitoring, etc).
2. Develops appropriate socialemotional and adaptive goals for children with diverse abilities, disabilities, backgrounds, strengths and needs.
3. Develops and implements (directly or via consultation) appropriate social/emotional/behavioral interventions that are linked to student needs.
4 . Evaluates effectiveness of social/emotional/behavioral interventions and makes appropriate changes based on empirical evidence.
NASP Domain 4 meets WI Department of Public Instruction Pupil Service Standards 2, 6
NASP Domain 5: School-Wide Practices to Support Learning
Unestablished Observer Novice
1. Demonstrates knowledge of basic school systems and what transpires in diverse classrooms (general ed, special ed, alternative ed).
Practicum I School Psychology Manual
Advanced
Novice
Not Observed
Advanced
Novice
Not Observed
Page 14

2. Understands the Wisconsin ten teacher standards.
3. Demonstrates knowledge of and/or participates in a multi-tiered continuum of school-based services
(ex., RtI for academics, PBIS)
4. Participates in the development of evidence-based strategies for effective school-wide policies and practices
(ex., discipline, instructional supports, staff training, program evaluation, grading, school improvement plans, transition planning).
NASP Domain 5 meets WI Department of Public Instruction Pupil Service Standards 1, 2, 5, 6
NASP Domain 6: Preventative and
Responsive Services
Unestablished Observer Novice
1. Demonstrates knowledge of principles and practices related to resiliency and risk factors in learning and mental health.
2. Demonstrates ability to seek out appropriate resources to assist with student and/or family needs (ex., resources for homeless families, access to community health or other services, abuse resources, etc).
3. Participates in the design, implementation, and evaluation of programs that address systematic problems (ex., school failure, truancy, dropout, bullying, school violence, youth suicide, etc)
NASP Domain 6 meets WI Department of Public Instruction Pupil Service Standards 2, 5, 6
NASP Domain 7: Family and School
Collaborations
Unestablished Observer Novice
1. Understands the characteristics of family, family strengths and needs, family culture, and family-school interaction that impacts learning.
Advanced
Novice
Not Observed
Advanced
Novice
Not Observed
Practicum I School Psychology Manual Page 15

2. Helps families to become active participants in their child’s education by promoting positive family-school interactions.
3. Identifies and navigates with sensitivity diverse cultural contexts and perspectives that impact familyschool communication and collaboration.
4. Utilizes evidenced-based problemsolving strategies, consultation, evaluation methods, and direct/indirect services to enhance family-schoolcommunity effectiveness in addressing the needs of children.
NASP Domain 7 meets WI Department of Public Instruction Pupil Service Standards 4, 5, 7
NASP Domain 8: Diversity in
Development and Learning
Unestablished Observer Novice
1. Demonstrates knowledge of principles and practices related to diversity factors (i.e., age, gender or gender identity, cognitive capabilities, social-emotional skills, developmental level, race, ethnicity, national origin, religion, sexual and gender orientation, disability, chronic illness, language, socioeconomic status).
2. Considers English proficiency when interacting with culturally and linguistically diverse students and making decisions about assessment and intervention.
3. Provides culturally competent practices in all areas of service.
NASP Domain 8 meets WI Department of Public Instruction Pupil Service Standards 4, 7
Advanced
Novice
Not Observed
Practicum I School Psychology Manual Page 16

NASP Domain 9: Research and Program
Evaluation
Unestablished Observer Novice
1. Demonstrates knowledge of research design, measurement, and varied methods of data collection techniques used in educational settings.
2 . Consumes research material and seeks information when he/she needs to increase his/her knowledge base.
3. Participates in the design and analysis of program evaluation.
NASP Domain 9 meets WI Department of Public Instruction Pupil Service Standards 3
NASP Domain 10: Legal, Ethical, and
Professional Practice
Unestablished Observer Novice
1. Understands the comprehensive roles and functions of the school psychologist (ex., foundations of school psychology; ethical, legal and professional standards related to professional identity; and effective practice as a school psychologist).
2. Understands and adheres to legislation and regulations relevant to education (i.e, IDEA, 504, NCLB,
FERPA, confidentiality, etc).
3. Seeks ongoing professional development opportunities (ex., state or national conferences, workshops, webinars, etc.)
4. Provides services consistent with ethical and professional standards in school psychology.
NASP Domain 10 meets WI Department of Public Instruction Pupil Service Standards 4
Advanced
Novice
Not Observed
Advanced
Novice
Not Observed
Practicum I School Psychology Manual Page 17

Professional Work Characteristics
1. Is appropriately/professionally dressed and well-groomed.
Rarely Often
2. Demonstrates reliability in work, attendance, and punctuality.
3. Is organized and demonstrates ability to plan ahead (e.g., preparing for assessments and meetings, having appropriate materials ready and available).
4. Takes initiative (i.e., commensurate with skills) without being asked.
5. Accepts supervision and incorporates constructive feedback openly and appropriately.
6. Is tactful and appropriate with teachers, families, and other service providers.
7. Clearly and concisely communicates to a diverse audience, both verbally and in written format.
Professional Work Characteristics meet WI Department of Public Instruction Pupil Service Standard 7
Comments from Mentor
I have completed the above evaluation and reviewed it with the practicum student.
________________________________________________
Signature of Field Supervisor
I have reviewed the above evaluation.
________________________________________________
Signature of Practicum Student
______________
Date
_______________
Date
I have reviewed the above evaluation.
________________________________________________
Signature of University Supervisor
________________
Date
Practicum I School Psychology Manual Page 18
Always

Appendix C
University of Wisconsin-Stout
Student: _______________________________ Date: _______________
Curriculum-Based Measurement Probes: ______________________________________________
Academic Intervention: _____________________________________________________________
Rater: _______________________________ Please Circle One: Practicum I Practicum II
Excellent = 5;
Evaluation Scale
Good = 4; Average = 3; Poor = 2; Very Poor = 1
1.
Behavioral Observations (clear, relevant, paints a behavioral “picture” of the child) 1 2 3 4 5
2.
Style and Communication (readable, professional appearance, no jargon, no 1 2 3 4 5 inconsistencies unless explained, clear)
3.
Intervention (clearly described, provides a rationale for the intervention of choice, 1 2 3 4 5 evidence-based)
4. Results (clearly explained and graphed)
5. Interpretations (reasonable, accurate, meaningful)
1 2 3 4 5
1 2 3 4 5
6. Summary (covers essential information, evaluates Intervention effects)
7. Recommendations (clear, realistic, tied to CBM results, at least three recommendations included)
8. Grammar
9. Spelling/Punctuation/Capitalization
10. Overall Rating
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
Practicum I School Psychology Manual Page 19

Appendix D
University of Wisconsin-Stout
Student: _______________________________ Date: _______________
Behavioral Intervention: ______________________________________________________________
Please, check one: Case Type (check one):
[ ] Practicum I
[ ] Practicum II
[ ] FBA [ ] Consultation [ ] Both
Excellent = 5;
Evaluation Scale
Good = 4; Average = 3; Poor = 2; Very Poor = 1
Problem Identification & Analysis (Circle One)
1. Behavioral Observations 1 2 3 4 5
(Behavior defined in context; operationally defines target behavior, discrepancy between current and desired levels of performance explained; appropriate use of measurement technique/tools during baseline and intervention cycles)
2. Functional Behavioral Assessment/Analysis 1 2 3 4 5
(Includes baseline, clear description of hypothesis linked with indirect and direct data sources, setting events, triggers, behavior, maintaining consequences, and function)
Intervention & Evaluation
3. Behavior Intervention Plan 1 2 3 4 5
(Clearly described and related to measurable goals, intervention is evidence-based and appropriate based on assessment data, all information used from summary/hypothesis statement; logistics of setting, time, resources, personnel described in plan)
4. Results 1 2 3 4 5
(Baseline and intervention graphs depict child’s response; clear description of response to the intervention based on baseline, trend, and goal line comparisons; description of needed/ attempted modifications based on data)
5. Discussion/ Summary 1 2 3 4 5
( Summarizes essential information, includes reasonable, accurate, and meaningful descriptions of problem and recommended changes to
FBI/BIP, includes strategies for transfer/ generalizing to other settings, follow-up strategies outlined)
6. Style and Communication
(Professional appearance, jargon-free, no inconsistencies unless explained, clear)
7. Grammar/Spelling/Punctuation/Capitalization
1 2 3 4 5
1 2 3 4 5
Practicum I School Psychology Manual Page 20

Child’s Name:
Name of Rater:
Consultant’s Name:
Appendix E
University of Wisconsin-Stout
Date:
Please rate the intervention/consultation experience using the following scale:
1
Strongly
Disagree
2
Disagree
3
Slightly
Disagree
4
Slightly Agree
5
Agree
6
Strongly Agree
1. I like the procedures used in this intervention.
2. This intervention is a good way to handle this
problem.
3. Overall, this intervention is beneficial
for this student.
4. This intervention is reasonable for the problem.
5. I would be willing to use this intervention in
the future.
6. I felt this intervention/ collaboration
was generally helpful.
7. I felt the consultant listened & responded
to my needs.
8. I felt my views/ideas were listened to and
used in developing the intervention.
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
5
6
6
6
6
6
6
6
6
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
9. The data were shared with me and I had an
opportunity to share my views.
1 2 3 4 5 6 N/A
Please briefly describe things that you felt went particularly well during this consultation/intervention planning, implementation, and evaluation, and suggestions for improvement.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Practicum I School Psychology Manual Page 21

Appendix F
University of Wisconsin-Stout
Student: Date:
Field-based Supervisor: Site:
Directions:
This form should be completed by the supervisor and discussed at the first site visit with the practicum student, field-based supervisor and university supervisor. Thank you for taking the time to complete this form. This will assist the student in developing a practicum plan.
1) The following are some examples of the ways in which supervisors provide supervision to their practicum students.
Please indicate which methods of supervision you can provide at this site.
□ Direct observation of student’s performance
□ Listening to or viewing sessions
□ Reviewing assessments and written case reports
□ Weekly case discussions
□ Other:
2) Which of the following activities are available at your site?
□ Assessment (Formal/Informal/ Academic/Cognitive/Social-Emotional)
□ Functional Behavior Assessments
□ Observation in Natural Environments
□ Curriculum-Based Measurements
□ Counseling (Individual/Co-facilitating Groups)
□ Academic Intervention (Individual/Class)
□ Behavioral Intervention/Prevention
□ Crisis Intervention/ Prevention
□ Assisting with System-Wide Intervention/Prevention
□ Consultation & Collaboration with Teachers and Staff
□ Observing Consultation & Collaboration with Community Agencies
□ Working with Culturally and Linguistically Diverse Students and their Families
□ Consultation and Collaboration with Families
□ In-service or Other Presentations
□ Assisting with Research/Program Evaluation
□ Assisting with Interagency Case Management
□ Assisting with Special Education Paperwork/Case Management
□ IEP and Team Meetings (observing, co-facilitating)
□ What professional development opportunities are available at this site?
____________________________________________________________________________________________
____________________________________________________________________________________________
 What are the unique opportunities of this site that have not yet been discussed?
____________________________________________________________________________________________
____________________________________________________________________________________________
Practicum I School Psychology Manual Page 22

Appendix G
University of Wisconsin-Stout
Directions: In collaboration with your site supervisor, please list one or more goals and objectives for each of the NASP domains. Refer to the Blueprint, Goals and Objectives of the UW-Stout School Psychology Practicum Handbook and the
Practicum Evaluation (Appendix B) for developing goals and objectives. Recognize that some goals are more appropriate for the earlier half of the school year while others ware more appropriate for later in the school year.
Use the following five (5) examples to help you and your field-based supervisor develop your practicum plan.
Examples of Goals & Objectives for a Practicum II (Second Semester) Student
1) Data-Based Decision Making and Accountability (e.g., document review, screening, assessment, progress monitoring, evaluation)
Goal: To gain knowledge and experience in using data to assist staff in making educational decisions.
Objectives: By the end of the semester or [insert date] I will:
1) Assist staff with Kindergarten screening and observe [supervisor] use the information to provide feedback to parents and staff
2) Complete a minimum of 7 comprehensive evaluations (e.g., classroom observations, file reviews, interviews, cognitive testing)
3) Observe at least two (2) Child Assistance Team Meetings
2) Consultation and Collaboration (with school staff, teachers, families, or other professionals)
Goals: To gain a greater understanding of how to collaborate with parents when designing and implementing interventions.
Objectives: By [insert date] I will:
1) Observe my supervisor consulting with teachers and staff and discuss problem-solving techniques used to effectively consult with others
2) Consult with at least one teacher to design, implement, and monitor a behavioral intervention
3) Observe at least one staffing where the school psychologist and staff discuss and consult on cases
3) Interventions and Instructional Support to Develop Academic Skills (e.g., planning/ implementation/evaluation of classroom or home instruction, individual remediation lessons, or therapeutic sessions):
Goals: To obtain experience in applying direct and indirect services to children with cognitive or academic needs.
Objectives: By [insert date] I will:
1) Conduct classroom observations in the DCD program
2) Co-facilitate a minimum of 5 homework help groups to students with autism
3) Assist a third grade teacher implement reading instruction and monitor the progress with the students using
CBMs
Practicum I School Psychology Manual Page 23

4) Interventions and Mental Health Services to Develop Social and Life Skills: (e.g., direct and indirect interventions, such as group or individual interventions/ counseling, classroom guidance)
Goals: To gain more knowledge and experience in delivering research-based individual and group services to address social-emotional concerns.
Objectives: By [insert date] I will:
1) Meet weekly with one highly disengaged student to provide “check-in” services. Interventions will be planned according to student needs and with consultation of my field-based supervisor
2) I will attend 4 district staff development workshops
3) With consultation from my field-based supervisor, I will provide intervention services to two adolescent females who are struggling with depression and anxiety. I monitor the effectiveness of the intervention services using observational or survey information.
7) Family–School Collaboration Services (e.g., engagement in school/community/committees,
inter-agency partnerships)
Goals: To identify family and community barriers and begin to identify and use family and community strengths to address these barriers and enhance the collaboration between schools, families, and communities.
Objectives: By [insert date] I will:
1) Observe at least 2 IEP meetings
2) Assist school staff in preparing a minimum of 2 families for upcoming meetings (e.g., calls to families in advance of meetings, sending agendas, following-up with parents, families, or community members)
3) Assist staff in problem-solving to address transportation issues for families attending Kindergarten Screening
Day
4) Provide a “School Information” booth for families attending parent-teacher conferences.
Practicum I School Psychology Manual Page 24

Appendix H
School Psychologist-in-Training:
Start Date:
Practicum Site:
Field-based Supervisor Contact Information:
University of Wisconsin-Stout
Check one: [ ]Practicum I [ ]Practicum II
End Date:
Supervisor:
Address:
Email: Phone:
Briefly describe the site activities that will be used to accomplish these goals/objectives in each domain. Be sure to include specific date by which you intend completing the objectives. Some may be completed earlier, while others may not be accomplished until the end of the semester. Revisit this document throughout the semester to adjust the pace and content.
1) Data-Based Decision Making and Accountability (e.g., document review, screening, assessment, progress monitoring, evaluation)
Goal:
Objectives:
2) Consultation and Collaboration (with school staff, teachers, families, or other professionals)
Goal:
Objectives:
3) Interventions and Instructional Support to Develop Academic Skills (e.g., planning/implementation/evaluation of classroom or home instruction, individual remediation lessons)
Goal:
Objectives:
4) Interventions and Mental Health Services to Develop Social and Life Skills (e.g., direct and indirect interventions, such as group or individual interventions/ counseling, classroom guidance)
Goal:
Objectives:
5) School-Wide Practices to Promote Learning (system level systems and structures to promote learning across a continuum of services for all students)
Goal:
Objectives:
6) Preventive and Responsive Services
Goal:
Objectives:
Practicum I School Psychology Manual Page 25

7) Family–School Collaboration Services (e.g., observing or participating in providing involving family communication, needs, and culture)
Goal:
Objectives:
8) Diversity in Development and Learning (individual differences, abilities, disabilities, their relation to service/research, etc.)
Goal:
Objectives:
Objectives:
9) Research and Program Evaluation (e.g., observing or assisting with evaluating outcomes of organization, systems, classroom, family or individual services)
Goal:
10) Legal, Ethical, and Professional Practice (e.g., history, service methods/models, legal and ethical standards, their relation to effective practice, etc.)
Goal:
Objectives:
In signing below I understand that I am indicating that I have read and agreed with the above stated goals and objectives.
Field-Based Supervisor Signature
Student Signature
University Supervisor Signature
Date
Date
Date
Practicum I School Psychology Manual Page 26

Appendix I
University of Wisconsin-Stout
Student: ______________________________________ Semester/Year: ___________________
School District: _________________________________ Field-Based Supervisor: ___________________
Please provide feedback on your Practicum Site by marking the appropriate box with an "x" in the following categories:
Strongly Disagree Neutral Agree Strongly
Agree Disagree
1. I had ample opportunities to use a variety of assessment methods.
2. I had ample opportunities to provide direct service to students.
3. I had ample opportunities for professional growth
(e.g., trainings, seminars, staff conferences).
4. I had ample opportunities to design, implement, and evaluate direct and indirect interventions.
5. I had adequate opportunities to work with diverse populations.
6. I would recommend this site as a first semester school psychology practicum placement.
7. I would recommend this site as a second
semester school psychology practicum placement.
Comments regarding this practicum site:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
---------------------------------------------------------------------------------------------------------------------
Please return to:
SPSY Practicum Instructor
University of Wisconsin-Stout
School of Education
410 McCalmont Hall
Menomonie, WI 54751
Practicum I School Psychology Manual Page 27

Name:
Assessment
Year:
Appendix J
School Psychology Log
Semester:
Evaluation for SPED (Cognitive/Academic/Social-Emotional)
Assist in Evaluation for Community Referral (mental health, ADHD, AODA)
Evaluation for Academic Intervention Planning (curriculum-based measurement)
Evaluation for Behavioral Intervention Planning (FBA)
Counseling & Intervention
Counseling Individuals
Co-facilitating Counseling Groups
Academic Intervention Implementation
Behavioral Intervention/ Prevention Implementation
Crisis Intervention / Prevention Implementation
Assisting in Systems-Wide Intervention/ Prevention Programs (classroom, school)
Consultation & Collaboration
Consultation & Collaboration with Teachers/ Staff
Observing Consultation & Collaboration with Community Agencies
Consultation & Collaboration with Families
Professional Policies & Development
SPED paperwork/ Case Management (calls, referrals)
Assisting with Interagency Case Management
Observing/ Co-facilitating Team Meetings (IEPs, student assistance teams)
Conference, Workshop, In-service Training Attendance
Assisting with Presenting/ Developing Workshops/Trainings
Time in Supervision
SEMESTER TOTAL
Diverse Populations - Estimate percentage of population worked with for semester
Caucasian
Latino/ Hispanic
Black/ African American
Asian/ Pacific Islander
American Indian
GLBT
Total Hours
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Practicum I School Psychology Manual Page 28

Appendix K
PRACTICUM I CHECKLIST (University Supervisor)
Student’s Name: _______________________________________
Reviewed by: ________________________________________
Information reviewed for completion of: [ ] Practicum I Date:________
[ ] Practicum II Date: ________
Forms Required
Practicum Data Sheet
Practicum Site Checklist
Practicum Plan
Midterm Evaluation – Self
Midterm Evaluation – Field Supervisor
Case Studies
Completed 10 cases?
Practicum I
YES/NO
Practicum II
YES/NO
From above cases, 3 were comprehensive?
Comprehensive Case studies using :
1. Curriculum-based Measurements (CBM)
2. Social-emotional Assessment
3. Psycho-educational Consultation
4. Functional Behavioral Assessment
5. Psycho-educational Report
Presented a case study during seminar
Final Evaluation - Self
Final Evaluation – Field Supervisor
Practicum Summary
Practicum Log Sheet – Weekly
Practicum Log Sheet – Cumulative (total hours)
Student Evaluation of Practicum Site
Exit Interview
(For Supervisors) Site Visit Summary
GRADE FOR COURSE
YES/NO YES/NO
39