FIELD EVALUATION
B.S.W. Field Placement
SWRK 4120
LEARNING CONTRACT AND SKILLS EVALUATION
SWRK4120 BSW Field Evaluation Form
IDENTIFYING INFORMATION
Field Placement Days: Mon. ☐ Tues. ☐ Wed. ☐ Thurs. ☐ Fri. ☐ Sat. ☐ Sun. ☐
TIME (example: 8 a.m. – 4 p.m.; 10 a.m. – 2 p.m.): Click here to enter text.
Reflective journal frequency (e.g., daily, weekly, bi-weekly, monthly): Choose an item.
Day(s) and time(s) of weekly field supervision: Choose an item.
Student
Click here to enter text.
Field Instructor*
Click here to enter text.
U of M Email
Click here to enter text.
Email
Click here to enter text.
Primary Phone
Click here to enter text.
Primary Phone
Click here to enter text.
Faculty /Field Liaison
Click here to enter text.
Agency Mentor*
(if applicable)
Click here to enter text.
Email
Click here to enter text.
Email
Click here to enter text.
Primary Phone
Click here to enter text.
Primary Phone
Click here to enter text.
Agency
Click here to enter text.
Contact Name
(if applicable)
Click here to enter text.
Address
Click here to enter text.
Email
Click here to enter text.
Fax #
Click here to enter text.
Primary Phone
Click here to enter text.
*Note: A Field Instructor must possess a social work degree and is appointed by the University to supervise
the student. An Agency Mentor is the onsite person who does not hold a social work degree but is
directly supervising the student and works in collaboration with the Field Instructor.
Please indicate below which Field Coordinator (Program) you are submitting this Evaluation form to:
☐ Distance Delivery BSW Field Program
Joan Churley, Field Coordinator
Distance Delivery BSW Field Program
Faculty of Social Work
University of Manitoba
joan.churley@umanitoba.ca
Phone: 204.474.6812
Toll Free: 1.800.432.1960 Ext: 6812
Fax: 204.474.7594
☐ Fort Garry & Inner City Field Programs
☐ Northern Social Work Program
Kelly Scott, Field Coordinator
Fort Garry & Inner City Social Work Field
Programs
Faculty of Social Work
University of Manitoba
kelly.scott@umanitoba.ca
Phone: 204.474.8300
Fax: 204.474.7594
Janet Brady, Field Coordinator
Northern Social Work Program
Faculty of Social Work
University of Manitoba
janet.brady@umanitoba.ca
Phone: 1.204.677.1456
Fax: 1.204.677.4110
2
SWRK4120 BSW Field Evaluation Form
LEARNING CONTRACT
The Learning Contract is an important tool in the field instruction process. Its purpose is to assist in making
learning goals and expectations explicit. The student develops it, collaboratively with the Field Instructor, and
in consultation with the Field Liaison. It is a working document, meant to be flexible and dynamic. It can be
assessed on an ongoing basis throughout the field placement and modified if required to acknowledge
changing needs and goals. The Learning Contract is to be completed prior to each of the five (5) skills sets
identified in this form. In other words, the Learning Contract flows throughout the Evaluation Form. There can
be several learning objectives for any section. An example of the Learning Contract is found below.
1.
Professionalism/Ethical Standards
Student practices as a professional and conducts self in a professional manner. The student is able to
articulate social work ethical principles that will guide professional practice.
LEARNING CONTRACT
More than one learning objective is appropriate
Objectives
Activities
Timeline
1- Practice personal reflection and
self-evaluation to assure
continued professional
development
-Discussions with supervisor
-Work on strategies that foster continual
growth (participate in all PD opportunities)
-Journaling on the strengths and challenges I
have had with clients
April 2015
2- Identify in practice major values
that support and challenge my
professional practice and identify,
analyze and apply strategies to
resolve ethical dilemmas
-Review the CASW Code of Ethics
-Discuss with co-workers how they face
ethical dilemmas
-Discuss with supervisor possible solutions
to ethical problems
April 2015
EVALUATION
One purpose of the Evaluation Form is to provide a standardized instrument that can provide a consistent
guide for Field Instructors and students to measure student performance. A Pass/Fail grade is intended to
encourage students to risk themselves in their professional development without risking a lower numerical
grade. The assessment of the student’s performance is meant to be progressive.
Each section contains a number of attributes that are to be evaluated. An explanation for assessing
knowledge/ability/skills at a 1, 2, 3, or a 4 can be found on the next page. Boxes titled “Example” follow each
attribute. Examples are mandatory whenever a student is assessed as not meeting expectations or when a
student requires further development in a particular skill set. Examples can also be made in other instances as
well.
There are three (3) grade recommendations to be considered. A Pass indicates that the student has met
expectations and has demonstrated skills at a 3 & 4 level. A Fail indicates that the student has failed to meet
expectations and has demonstrated the majority of skills at a 1 or 2level. A Fail Incomplete indicates that the
student is required to continue in SWRK 4120 for a defined period, as contracted with the student, Field
Instructor, and Faculty Field Liaison. Examples for the four (4) assessments levels follow on the next page. It is
also acceptable to use not applicable (N/A) or not observed (N/O) if a student has not had the opportunity to
demonstrate or practice this skill set, or if the Field Instructor has not been able to evaluate a particular
attribute of a skill set.
3
SWRK4120 BSW Field Evaluation Form
1) Does Not Meet Expectations: The student fails to
demonstrate the necessary skills and abilities. Some
examples are:








Unable to establish clear boundaries with clients
Unable to describe criteria to determine success of
interventions
Does not work collaboratively with client
Cannot articulate issues related to diversity in
social work practice
Unable to engage involuntary clientele
Student unable to incorporate feedback/direction
in their work
Does not set goals in partnership with clients
Lacks initiative for their learning while in
placement
Action: Field Instructor and Field Liaison will complete the
formal Learning Contract addendum, or discuss
termination.
3) Meets Expectations: The student would receive a “3”
when s/he demonstrates identified skills on a
regular basis. Examples include, but are not limited to:





Student is able to implement interventions
grounded in theory
Student demonstrates critical thinking when
engaged in supervision
Student takes risks and uses a variety of strategies
when engaging with challenging clients
Student recognizes and comprehends the impact
of policy at the micro, macro and mezzo level
Student is able to complete documents that serve
a range of purposes such as assessments or
funding proposals and for a variety of readers
(funders, clients, co-workers).
2) Needs Development: The student demonstrates
potential for growth in his or her professional role, but
in an inconsistent manner. Some examples are:






Documentation is not always clear or completed in
a timely fashion
Student is starting to become comfortable using a
range of communication skills
Student is starting to describe the theoretical
frameworks that were used when developing
assessments and intervention plans
Is beginning to critically examine the effectiveness
of their work
Student still needs support from the field
instructor before client meetings or at meetings
with clients.
Needs to be reminded of agency policies and
procedures
Action: Field Instructor and Field Liaison will review on a
regular basis the skills that have been identified for
development.
4) Integrates Theory and Skills: The student would
receive a “4” when s/he demonstrates competence or
exceptional skills on a consistent basis. Examples
include, but are not limited to:

Student is able to independently design research
and evaluation components on community
projects and complete the projects.

Always behaving as a fully developed professional
person

Demonstrated consistent integration of theory
and use of professional judgement in all
interventions

Student an competently and confidently act on
behalf of the agency
Note: In this evaluation Client can refer to individuals, families, community groups, and/or organizations
4
SWRK4120 BSW Field Evaluation Form
1
Does Meet
Expectations
1.
2
Needs
Development
3
Meets
Expectations
4
Integrates Theory
and Skills
N/A
(Not Applicable)
N/O
(Not Observed)
Professionalism/Ethical Standards
Student demonstrates social work principles and values in practice, and actively engaged in one’s learning.
LEARNING CONTRACT
More than one learning objective is appropriate
Objectives
Click here to enter text.
1.1
Activities
Click here to enter text.
Demonstrates the use of knowledge and skills of a professional social
worker.
Examples:
Click here to enter text.
1.2 Demonstrates confidence in carrying out the agency’s mandate.
Timeline
Click here to enter text.
Mid Term
Final
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Instructor
Student
Instructor
Student
Examples:
Click here to enter text.
1.3
Documentation and practice reflects a respectful and unbiased position
toward the client.
Instructor
Student
Examples:
Click here to enter text.
1.4
Able to clarify, develop, maintain, and reinforce professional
boundaries.
Examples:
Click here to enter text.
1.5 Identifies ethical issues in practice and discusses them with instructor in
the context of the student’s own values, CASW Code of Ethics and a
Instructor
Student
Instructor
5
SWRK4120 BSW Field Evaluation Form
resolution to the issue.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Student
Examples:
Click here to enter text.
1.6
Respects clients’ privacy and promotes the rights of clients to selfdetermination.
Examples:
Click here to enter text.
1.7 Other
Instructor
Student
Instructor
Student
Examples:
Click here to enter text.
Comments
You must make summary comments at Midterm (include additions and changes to the learning activities and objectives):
Click here to enter text.
You must make summary comments at Final:
Click here to enter text.
6
SWRK4120 BSW Field Evaluation Form
1
Does Not Meet
Expectations
2.
2
Needs
Development
3
Meets
Expectations
4
Integrates Theory
and Skills
N/A
(Not Applicable)
N/O
(Not Observed)
Assessment and Intervention Skills in Practice
The student uses self effectively, and competently demonstrates communication, engagement, assessment,
intervention, and documentation skills.
LEARNING CONTRACT
More than one learning objective is appropriate
Objectives
Click here to enter text.
2.1
Activities
Timeline
Click here to enter text.
Competence in using a range of interpersonal communication skills
(e.g. reflection, clarification, paraphrasing and questioning).
Click here to enter text.
Mid
Term
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
Choose
Final
Instructor
Student
Examples:
Click here to enter text.
2.2
Demonstrates ability to work with complex situations and with involuntary
and challenging clients.
Instructor
Student
Examples:
Click here to enter text.
2.3
Effectively conducts meetings/interviews with clients and collaterals.
Instructor
Student
Examples:
Click here to enter text.
2.4
Student is able to articulate and intervene on relevant concerns and goals
with clients.
Instructor
Student
Examples:
Click here to enter text.
2.5
Student is able to integrate theoretical knowledge into practice by
Instructor
7
SWRK4120 BSW Field Evaluation Form
providing rationale for their assessments and interventions.
an item.
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Student
Examples:
Click here to enter text.
2.6
Student identifies and actively collaborates with clients to build social
networks and social supports.
Instructor
Student
Examples:
Click here to enter text.
2.7
Reviews and evaluates clients’ progress toward established goals and
modifies goals when it is necessary and with client input.
Instructor
Student
Examples:
Click here to enter text.
2.8
Student is able to work collaboratively with a variety of systems and
disciplines.
Instructor
Student
Examples:
Click here to enter text.
2.9
Other
Instructor
Student
Examples:
Click here to enter text.
Comments
You must make summary comments at Midterm (include additions and changes to the learning activities and objectives):
Click here to enter text.
You must make summary comments at Final
Click here to enter text.
8
SWRK4120 BSW Field Evaluation Form
1
Does Not Meet
Expectations
3.
2
Needs
Development
3
Meets
Expectations
4
Integrates Theory
and Skills
N/A
N/O
(Not Applicable)
(Not Observed)
Reflective Capacity and Critical Analysis
The student engages in constructive discussions and reflections of self, clients and service delivery.
LEARNING CONTRACT
More than one learning objective is appropriate
Objectives
Click here to enter text.
3.1
Activities
Timeline
Click here to enter text.
The student is able to engage in the process of critical thinking and of an
examination of one’s own beliefs, values, actions, and reactions to others.
Click here to enter text.
Mid
Term
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Final
Instructor
Student
Examples:
Click here to enter text.
3.2
Demonstrates an ability to apply critical and constructive feedback from
the Field Instructor.
Instructor
Student
Examples:
Click here to enter text.
3.3
Student is consistently applying theories of practice, personal judgement,
and communication skills when working on the client’s behalf.
Instructor
Student
Examples:
Click here to enter text.
3.4
Discusses ethical dilemmas with the field instructor for the purpose of
resolution.
Instructor
Student
Examples:
Click here to enter text.
9
SWRK4120 BSW Field Evaluation Form
3.5
Consistently critically evaluates one’s own practice and responds
appropriately to feedback.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Instructor
Student
Examples:
Click here to enter text.
3.6
Other
Instructor
Student
Examples:
Click here to enter text.
Comments
You must make summary comments at Midterm (include additions and changes to the learning activities and
objectives):
Click here to enter text.
You must make summary comments at Final
Click here to enter text.
10
SWRK4120 BSW Field Evaluation Form
1
Does Not Meet
Expectations
2
Needs
Development
3
Meets
Expectations
4
Integrates Theory
and Skills
N/A
(Not Applicable)
N/O
(Not Observed)
4. Promotion of Human Rights and Social Justice
Students demonstrate an awareness of global and anti-oppressive practice as they apply to their field
placement.
LEARNING CONTRACT
More than one learning objective is appropriate
Objectives
Click here to enter text.
4.1
Activities
Timeline
Click here to enter text.
Articulates and demonstrates how issues of inequality in society
(e.g. diversity, oppression, discrimination, power, ethno-culture, human
diversity, and privilege) impact the client.
Click here to enter text.
Mid
Term
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Final
Instructor
Student
Examples:
Click here to enter text.
4.2 Empowers clients to advocate for their own basic human rights
(e.g., freedom, safety, privacy, an adequate standard of living, health care,
and education.)
Instructor
Student
Examples:
Click here to enter text.
4.3 Respects and advocates for rights of others, and brings to the attention of
the field instructor any human rights concerns.
Instructor
Student
Examples:
Click here to enter text.
4.4 Demonstrates the importance to practise with cultural sensitivity.
Instructor
Student
11
SWRK4120 BSW Field Evaluation Form
Examples:
Click here to enter text.
4.5 Demonstrates leadership in promoting a safe environment for clients and
co-workers.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Instructor
Student
Examples:
Click here to enter text.
4.6
Other
Instructor
Student
Examples:
Click here to enter text.
Comments
You must make summary comments at Midterm (include additions and changes to the learning activities and
objectives):
Click here to enter text.
You must make summary comments at Final
Click here to enter text.
12
SWRK4120 BSW Field Evaluation Form
1
Does Not Meet
Expectations
2
Needs
Development
3
Meets
Expectations
4
Integrates Theory
and Skills
N/A
N/O
(Not Applicable)
(Not Observed)
5. Integration of Policy and Practice
Student demonstrates the knowledge and skills required to integrate policy into social work practice.
LEARNING CONTRACT
More than one learning objective is appropriate
Objectives
Click here to enter text.
5.1
Activities
Timeline
Click here to enter text.
Student identifies how policies at all levels impact practice within the
agency and upon clients.
Click here to enter text.
Mid
Term
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
Choose
Final
Instructor
Student
Examples:
Click here to enter text.
5.2
Student demonstrates analytical skills through written analysis of social
issue(s), including relevant social policy.
Instructor
Student
Examples:
Click here to enter text.
5.3
Actively involved in research and clinical evaluation.
Instructor
Student
Examples:
Click here to enter text.
5.4
Awareness of the various Canadian social welfare programs: able to identify
limitations and help clients navigate and access the programs that they may
require.
Instructor
Student
Examples:
Click here to enter text.
5.5
Student can conduct needs assessments/community asset mapping and can
Instructor
13
SWRK4120 BSW Field Evaluation Form
articulate relevant social issues.
an item.
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Choose
an item.
Student
Examples:
Click here to enter text.
5.6
Student is competent with assisting communities, groups and organizations
in mobilizing on significant issues.
Instructor
Student
Examples:
Click here to enter text.
5.7
Other
Instructor
Student
Examples:
Click here to enter text.
Comments
You must make summary comments at Midterm (include additions and changes to the learning activities and
objectives):
Click here to enter text.
You must make summary comments at Final
Click here to enter text.
14
SWRK4120 BSW Field Evaluation Form
Learning Contract Signatures
Date
Field Instructor (BSW, MSW, PhD):
Click here to enter a date.
Student:
Click here to enter a date.
Agency Mentor:
Click here to enter a date.
Faculty Field Liaison:
Click here to enter a date.
Midterm Evaluation Signatures
Date
Field Instructor:
Click here to enter a date.
Student:
Click here to enter a date.
Agency Mentor:
Click here to enter a date.
Faculty Field Liaison:
Click here to enter a date.
☐ Time Sheets submitted
Number of Hours Completed:
☐ Journals submitted
COMMENTS: Click here to enter text.
Final Evaluation Signatures
Date
Field Instructor:
Click here to enter a date.
Student:
Click here to enter a date.
Agency Mentor (if applicable):
Click here to enter a date.
Faculty Field Liaison:
Click here to enter a date.
☐ Time Sheets submitted
Number of Hours Completed:
☐ Journals submitted
COMMENTS:
Click here to enter text.
Signatures acknowledge that all parties have participated in a discussion and have an understanding of this
evaluation.
Once signed, this page MUST BE SENT IN to the Faculty Field Liaison (faxed, scanned/email).
A copy of the student’s SWRK 3150 Evaluation is forwarded to the student’s second Field SWRK 4120 Field
instructor. Identified skills requiring continued development will be recommended for transfer to SWRK 4120.
If at SWRK 3150 Final Evaluation the student has (2) two or more N/0’s, the skill(s) will be identified and will be
recommended to be carried over to the SWRK 4120 Learning Contract.
Grade Recommendation
☐ Pass
☐ Fail
☐ Fail Incomplete
15