Richmond Community Schools Psychologist Support Program
Feedback Form
Psychologist
Observer
Time:
Date:
Directions
Step 1. Psychologist and Observer will examine all evidence from the lesson.
(observer’s notes, etc.)
Step 2. Psychologist and Observer will highlight or circle the relevant parts of the statements
from the Levels of Performance by component for each Domain.
Step 3. Psychologist and Observer will check all components where evidence was found and
summarize evidence.
Step 4. Psychologist and Observer will review the Domain summaries and develop strategies
for future practice.
1
Psychologist:
Observer:
Date:
Richmond Community Schools Psychologist Support Program: Feedback Form
Domain 1: Planning and Preparation
Component
Level of Performance
UNSATISFACTORY
BASIC
PROFICIENT
DISTINGUISHED
1a:
Demonstrating
Knowledge of School
Psychology
Displays little understanding of the
subject, structure of the discipline, or
of content-related psychoeducational principles.
Psycho-education knowledge
represents basic understanding, but
does not extend to connections with
other disciplines.
Demonstrates solid understanding of
content, prerequisite relationships
and connections with other
disciplines. Responsibilities reflect
current psycho-educational
knowledge.
Knowledge of practice of school
psychology is extensive with evidence
of a continuing search for improved
practice.
1b:
Demonstrating
Knowledge of Students
Makes little attempt to acquire or use
knowledge of students’ backgrounds,
skills, or interests.
Uses appropriate instruments and
demonstrates culturally competent
practices to gain knowledge of
students’ backgrounds, skills and
interests.
Psychologist gathers information
from parents in a culturally
competent manner as well as
previous teachers and caregivers to
gain knowledge of students’
backgrounds, skills, and interests.
Demonstrates all proficient level criteria
and also contacts relevant community
resources. Promotes partnership with
family and school.
1c:
Addressing Referral
Questions
Assessment and consultation do not
address referral question/problem.
Fails to tailor choice of tools to
individuals needs.
Assessment and consultation address
referral question/problem as
presented. Uses standard test battery
with little variation to specific
student needs.
Comprehensively addresses referral
question/problem and identifies
related issues. Selects instruments
based on individual needs and
problem. Has and uses a variety of
test instruments.
Thoroughly response to referral problem
and related issues, facilitates problem
solving, and provides appropriate
resources and intervention techniques.
Creatively approaches referral question,
using a variety of standardized test and
developing curriculum-based measures.
1d:
Demonstrating
Knowledge of School,
District, and Community
Resources
Displays little knowledge and
understanding of the available
resources.
Has knowledge and understanding of
the available resources within the
immediate educational setting.
Has more detailed knowledge and
understanding of the resources
available within the immediate
education setting, school district, IU,
and community.
Participates in and accesses a network of
child serving agencies to provide
seamless services to the child, family
and school.
1e:
Complies with
Procedural Guidelines
Repeatedly disregards timelines or
fails to adhere to procedural
safeguards.
Attentive to timelines and adheres to
procedural safeguards.
Works with school-based team and
parents to ensure that all procedural
safeguards are consistently followed.
Conducts training with school staff to
ensure understanding, collaboration and
compliance with timelines and
procedural safeguards.
2
Psychologist:
Observer:
Date:
Richmond Community Schools Psychologist Support Program: Feedback Form
Planning and
Preparation
(Check all components
where evidence was found.)
Demonstrating Knowledge of School Psychology
Demonstrating Knowledge of Students
Addressing Referral Questions
Demonstrating Knowledge of School
District, & Community Resources
Complies with Procedural Guidelines
Summary
Strategies for Future Practice
3
Psychologist:
Observer:
Date:
Richmond Community Schools Psychologist Support Program: Feedback Form
Domain 2: The Assessment Environment
Component
Level of Performance
BASIC
PROFICIENT
DISTINGUISHED
2a:
Interaction with Parents
and Teachers
Interactions are negative,
demeaning, or inappropriate to
the culture of the parent.
UNSATISFACTORY
Interactions are appropriate but
occasionally do not reflect equal
partnerships, mutual respect, or
regard for differences in culture
or values.
Interactions are characterized by
civility, mutual respect, give and
take, and a sense of partnership,
questions are encouraged and
answered.
Contacts parents and teachers in
advance to discuss concerns and
goals for evaluation, what will be
done and when, what to tell the
child, how to reduce child’s anxiety,
and removal from class. Explains
MDE and IEP procedures.
Interviews and feedback are timely,
respectful, empathetic and
collaborative; respect time
limitations; and are clear with a
minimal use of technical terms.
2b:
Interaction with
Students
Interactions are negative,
demeaning, or inappropriate to
the age or culture of the student.
Interactions are developmentally
and situationally appropriate.
Efforts to establish rapport and
adequate to ensure validity of
results.
Interactions are caring, friendly,
respectful, and developmentally
and culturally appropriate.
Questions are answered in
accordance with instrument
limitations. Uncooperative
students are responded to with
patience.
Interactions are warm, caring and
respectful. Procedures are explained
and questions answered within
limitation of instruments.
Psychologist ensures student is at
ease, cooperative, comfortable
asking and responding to questions,
and respectful. Uncooperative
students are responded to
therapeutically with patience,
understanding, and empathy.
2c:
Importance of Preparing
the Student
Student is not prepared prior to
test administration. Anxious
reactions to departure from
classroom or to test procedures
are not addressed.
Time is spent preparing student
for evaluation. Student anxiety is
addressed periodically with
encouragement and efforts to
relax the student.
Efforts to put student at ease
begin at first meeting. Reasons
for activities are given in
developmentally appropriate
language; questions are answered
within instruments’ limitations
and in friendly manner. Feedback
is given as permitted by the
instruments.
Student is asked to test area in
careful manner. Evaluation,
activities and levels of difficulty are
explained in developmentally
appropriate language and within
instrument limitations; questions are
encouraged. Psychologist conveys
that student is active participant and
that responses are valued and creates
atmosphere of cooperation.
4
2d:
Managing Student
Behavior during
Evaluation
Psychologist does not monitor or
address negative test behaviors
Psychologist is alert to
problematic behaviors and takes
steps to intervene.
Is alert and anticipates
problematic behaviors and
proactively takes steps to
intervene. Uses developmentally
appropriate encouragement or
incentives. Addresses
uncooperative or disruptive
behaviors with gentle but firm
limit settings.
Is sensitive to emerging fatigue and
reduced motivation and attention
and takes steps to intervene.
Addresses uncooperative or
disruptive behaviors with gentle but
firm limit setting and a sense of
humor.
2e:
Managing Assessment
Procedures
Psychologist is unfamiliar with
relevant procedures and fails to
administer or score according to
acceptable practices. Test
administration is not modified as
needed.
Does not observe or modify
testing room limitations. Does
not reduce distractible stimuli
when possible. Does not take
steps to ensure safety.
Demonstrates competency in
procedures for each measure and
adheres to standardized
administration.
Psychologist is well versed in
multiple procedures and
administers them according to
standardized specifications and
special needs.
Uses innovative strategies and
techniques to optimally assess the
student’s needs. Procedures are
adapted to accommodate for special
needs and circumstances.
Observes and modifies testing
room limitations. Reduces
distractible stimuli and ensures
safety. Ensures appropriate
conditions with building
administrator. Modifies test
administration based on
environmental conditions.
Inspects and modifies, to extent
possible, rooms in advance for
distractions, lighting and
temperature. Arranges furniture
to maximize efficiency of
administration, optimize
attention/activity level, and
maximize safety. Discontinues
testing if conditions become
adverse or counterproductive.
Consults with building and district
administration to promote the
availability of optimal testing
conditions.
Protected test materials, scoring
forms, and notes are not stored in
a secure area and access to
records is not monitored.
Protected test materials, scoring
forms, and notes and stored in a
secure area when one is
provided.
Consults with building
administrator to store protected
test materials, scoring forms, and
notes in a secure, locked area.
Keeps and review and access log.
Consults with district administrator
to ensure policy that allows for
storing protected materials, forms,
and notes in a secure area. Keeps a
log to monitor and record access to
records by authorized personnel
only.
2f:
Organizing Testing
Rooms
2g:
Organizing Storage
Space
5
Psychologist:
Observer:
Date:
Richmond Community Schools Psychologist Support Program: Feedback Form
The Classroom
Environment
(Check all components
where evidence was found.)
Interaction with Parents and Teachers
Interaction with Students
Importance of Preparing the Student
Managing Student Behavior during Evaluation
Managing Assessment Procedures
Organizing Testing Rooms
Organizing Storage Space
Summary
Strategies for Future Practice
6
Psychologist:
Observer:
Date:
Richmond Community Schools Psychologist Support Program: Feedback Form
Domain 3: Consultation
Component
Level of Performance
UNSATISFACTORY
BASIC
PROFICIENT
DISTINGUISHED
Demonstrates thorough
understanding of client needs.
Facilitates the development of
clear and concise strategies
that are timely and effective.
Follow up provided as
necessary.
Uses process skills effectively
resulting in marked degree of
client cooperation in
communicating and
collaborating.
Clients seek the involvement of
psychologist in solving
problems. Strategies are
consistently monitored and
revised as necessary to promote
problem solving. Collaboration is
ongoing.
Highly proficient use of process
skills resulting in a degree of
client cooperation in
communicating and collaborating
that allows for exploration of
other concerns in greater depth.
Strives to expand knowledge and
expertise of self, colleagues, coworkers and community.
3a:
Providing Consultation
to Clients
Does not understand client
concerns. Does not provide
timely, useful or practical
strategies.
Demonstrates basic
understanding of client needs.
Strategies are sound.
3b:
Communicates
Effectively
Does not utilize process skills
(i.e. empathy, genuineness,
and warmth) necessary for
establishing client
cooperation, trust, and
rapport.
Lacks awareness of own
limits of knowledge and
expertise. Consults outside the
boundaries of knowledge.
Uses process skills when
communicating and
collaborating to engender
client cooperation.
Stays appropriately within
boundaries of knowledge and
expertise.
Has expert knowledge and
competency in addressing
referral problems. Maintains
professional boundaries.
Fails to evaluate
implementation and
effectiveness of consultation.
Collects information about
interventions in a timely
manner that allows program
adjustment as needed.
Integrates evaluation with the
design of the consultation so
that data collection and
program adjustment are
ongoing processes.
Does not participate in or
attend team meetings when
required. Participation in
meetings undermines team
process/climate.
Participates in team meetings.
Needs supervision and
direction about participation.
Participates actively,
consistently, and
constructively in team
meetings. Assists in
developing positive
behavioral intervention
strategies.
3c:
Consults within
Boundaries of
Competence and
Expertise
3d:
Evaluates Effectiveness
and Integrity of
Consultation
3e:
Involvement on Building,
District, and Interagency
Teams
Psychologist facilitates data
collection that permits client to
make ongoing evaluation and
necessary modifications. Client
implements intervention
strategies with integrity.
Facilitates team meetings.
Anticipates and plans for team
needs. Assists in developing
positive behavioral intervention
strategies.
7
Psychologist:
Observer:
Date:
Richmond Community Schools Psychologist Support Program: Feedback Form
Consultation
(Check all components
where evidence was found.)
Providing Consultation to Clients
Communicates Effectively
Consults within Boundaries of Competence
& Expertise
Evaluates Effectiveness & Integrity of
Consultation
Involvement on Building, District,
& Interagency Teams
Summary
Strategies for Future Practice
8
Psychologist:
Observer:
Date:
Richmond Community Schools Psychologist Support Program: Feedback Form
Domain 4: Professional Responsibilities
Component
Level of Performance
UNSATISFACTORY
BASIC
PROFICIENT
4a:
Validity of Assessment
Uses methodology that is
unreliable or invalid relative to
the presenting problem.
Uses methodology that is
appropriate to the presenting
problem. Follows standardized
procedures and ensures accuracy.
Generates and communicates an
integrated profile of the student
in their learning environment.
4b:
Accuracy of Contact
Notes, Reports, and
Protocols
4c:
Quality and Timeliness
of Feedback
Records are not fount, not legible
or not secure. Important data may
be missing.
Keeps systematic and accurate
records.
Records are complete, accurate,
legible and organized.
Provides meager or inaccurate
information about student
performance, interventions,
programs or other relevant issues.
Offers basic information to
teachers and parents about
student performance,
interventions, programs, or other
relevant issues.
Provides extensive information
and considers parents’
communication needs. Involves
teachers and parent in the
intervention process.
4d:
Enhancement of
Professional Knowledge
Engages in few or no
professional development
activities to enhance knowledge
or skill.
Participates in professional
activities as required.
Seeks out opportunities for
development to enhance
professional knowledge and
practice.
4e:
Service to the Profession;
Staff Development
Makes little or no effort to
promote professional
improvement through sharing
knowledge; fails to assume
professional responsibilities.
Participates in school practices
that are indifferent needs of some
students; sensitive to cultural
and/or ethnic issues.
Supports professional
improvement in others. Is
available to staff when needed.
Makes decisions that are biased,
unethical or unsupported by data.
Decisions are data driven and
reflect the needs of the client.
Offers staff training and makes
ongoing effort to promote
professional improvement;
actively participates in assisting
colleagues.
Works within the context of
teams, committees, and groups to
ensure all students a fair
opportunity to succeed. Sensitive
to social and cultural issues.
Decision-making is guided by
best practice and interest of
client; participates in team
decision-making.
4f:
Advocacy
4g.
Decision Making
Works within the context of
teams, committees, and groups to
ensure all students a fair
opportunity to succeed.
DISTINGUISHED
Generates and communicates and
integrated profile of the student in
their learning environment. Works
with the MDT to design
interventions based on assessment
results.
Records are complete, secure,
legible, and understandable to
another qualified professional in the
event of psychologist’s absence.
Provides extensive information
designed to meet parents’
communication needs and encourage
parental involvement. Maintains
contact to ensure continuing
cooperation and involvement.
Makes a systematic effort to
enhance professional skills; applies
and shares new knowledge.
Initiates important activities to
contribute to profession, such as
needs assessments, staff
presentations, interventions, articles,
and mentoring.
Challenge negative attitudes and
practices and helps ensure all
students are treated fairly; promotes
awareness of and sensitivity to
cultural diversity.
Takes a leadership role in team
decision-making and helps ensure
decisions are based on highest
professional standards.
9
Psychologist:
Observer:
Date:
Richmond Community Schools Psychologists Support Program: Feedback Form
Professional
Responsibility
(Check all components
where evidence was found.)
Validity of Assessment
Accuracy of Contact Notes, Reports
& Protocols
Quality & Timeliness of Feedback
Enhancement of Professional Knowledge
Service to the Profession; Staff Development
Advocacy
Decision Making
Summary
Strategies for Future Practice
Psychologist
Principal
Date
Date
Signature does not mean acceptance or rejection of evaluation-only that the teacher has examined this evaluation and has a copy of same. The
teacher may include a response or rebuttal to the evaluation.
This document is retained at the building by the building principal.
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