HDFS 299 Practicum Supervisor Feedback Form

Student:
Site: Date:
Practicum Supervisor(s)/Evaluator(s):

NOTE TO SUPERVISORS/EVALUATORS: Your honest feedback on this form and to your

student supervisee is greatly appreciated. That said, the content of this feedback form and the
related mid-semester and end of semester meeting to review and discuss progress towards
identified goals, student professionalism in general, etc. IS NOT FACTORED INTO THE
STUDENTS ACADEMIC GRADE FOR THE COURSE, provided minimum expectations are
being met. The feedback form and process is designed as a means for the Academic Instructor to
confirm the the student is engaging in the practicum experience for the required number of hours
and in a professionally responsible manner to at least a minimum level of expectation, but it is
primarily requested of you to provide the student an opportunity to practice this kind of process
and gain important feedback about professionalism and learning/development over the course of
the practicum.
Is a mid- or end of semester evaluation? ___ Mid-semester ___ End Semester

Rating Scale:
5= Excellent; No additional work needed.
4= Good; Fine-tuning in performance/skill level will result in excellence.
3= Acceptable; Performance/skill will improve with additional practice/mentoring.
2= Below average; Remedial help is needed to achieve acceptable level of performance.
1= Major problem; Special measures needed to correct the situation.
N/A = Not Applicable

I. Interpersonal Skills RATING

1. Maintains good relationships with co-workers
2. Practices a professional relationship with clients
3. Shows respect and acceptance of others
4. Receptive to feedback/suggestions
5. Expresses acceptance and displays non-judgmental attitudes of co-workers,
clients, and other professionals or community members
6. Exhibits an ability to work with other community agencies and personnel
II. Intrapersonal Skills RATING
1. Exhibits self-confidence
2. Demonstrates an ability to adjust to change
3. Practices good problem solving skills
4. Sets goals and has good decision making skills
5. Seeks out resources, help or additional information when needed
6. Displays a positive attitude/ optimistic
7. Demonstrates self-reflection on internship experiences
III. Communication Skills RATING
1. Communicates orally in an effective manner
2. Written communications are clear and effective
3. Practices good listening skills with clients and co-workers
4. Articulates ideas, concerns, and reflections in an effective manner
IV. Work Performance RATING
1. Demonstrates promptness and dependability
2. Displays enthusiasm for work and the agency
3. Submits projects and other work on time
4. Work is of high quality
 IV. Work Performance Contd. RATING
5. Conveys a willingness to assume responsibility
6. Exhibits effective planning and organizational skills
7. Uses creativity in projects, programs, or problem solving
8. Shows an ability to provide for client needs
9. Demonstrates good time management skills
10. Displays self motivation or initiative
11. Exhibits an openness to feedback and constructive criticism
12. Works assigned days and hours and communicates about attendance
V. Presentation Skills RATING
1. Uses effective presentation techniques for target audience
2. Voice projection/modulation is clear and understandable
3. Demonstrates the ability to focus and gain interest of participants at the
beginning of the session
4. Classroom/group management provides for a safe environment
5. Checks for understanding throughout lesson or seminar
6. Provides clarity in giving directions and delivering content
7. Questioning techniques encourage audience participation
VI. Overall Rating of Students Performance (Using Scale as Above)
May this completed feedback form be shared with the student?

If this is a mid-term evaluation, please address the following on a separate page:

1. Please review the Serving & Learning Contract you and the student agreed to at the start
of this field experience. How well is the student making progress towards the identified
learning goals that you were to be supporting and/or evaluating? What if any changes
do you believe NEED to be made to the contract in these areas? Please describe.
2. What about any changes you would recommend so as to improve the service provided by
the student, the learning opportunities offered to the student, or both?
3. Are there any particular areas of concern you would like the students faculty supervisor
to be aware of and/or to help you work with the student on? If yes, please explain.

If this is an end of the term evaluation, please address the following on a separate page:
1. Please summarize the students strengths as a direct service provider/field worker.
2. Please review the Serving & Learning Contract you and the student agreed to at the start
of this field experience. How well would you say the student progressed towards the
identified learning goals that you were to be supporting and/or evaluating?
3. Please identify any specific suggestions or recommendations you for this student as ze
continues on per developmental and professional journey.
4. Please share any additional commentsabout the student, the HDFS field experience
structure, your agencys needs for the future, etc.

Site Supervisor Completing Form:

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Printed Name Signature