Student
Cell phone
Course/Semester
EBPP
No
Paid
Liaison Monitoring Summary
Instructor
Cell phone
Email
Unpaid
Preceptor
Cell phone
Email
NOTE: THIS FORM IS DESIGNED TO BE COMPLETED ELECTRONICALLY.
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Routine Placement Monitoring
When
Type of
Date(s)
Contact
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Problem Area
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Documentation of Practicum Concerns
When
Type of
Date(s)
Contact
Placement problems/irregularities
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Area
Comments
Documentation of Student Performance Problems
Please describe performance problems in behavioral terms and date all important developments.
Level Review
Date
Summary
Disposition
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Date
Date
Performance Improvement Plans
PIP’s are developed for insufficient & unacceptable performance in practicum.
Plan (PIP)
Monitoring Progress Notes
Proposed Plan to Repeat Practicum
Proposed Plan
Plan Monitoring
School Decision
Liaison Evaluation of Field Instructor & Site
Instructor
Site
Faculty Liaison Signature: ______________________________________________________________
Rev 11/16/11