Form 4 (M) Therapeutic Recreation Mid-Term Evaluation of Student This mid-term evaluation is designed as a working tool for the Agen¢y Supervisor to provide clinical evaluation of the student at the mid-point of the intemnship experience. Name: Gacha_Gordan | Intemship Agency: Naw Haver. RC Agency TR Supervisor: Flavia Liv, Rating Scale 1 Consistently does not meet expectations 2 Needs improvement in meeting expectations 3 Meets expectations 4 Consistently exceeds expectations 5 Frequently exceeds expectations na —_Job task has not be introduced Part One: Performance Criteria Professional Relationships and Responsibilities 1 [2 [3 [4 [5 [na Establish/maintain effective working relationships v CCreate/maintain a safe and therapeutic environment Maintain CTRS/required state credential(s) v Participate in in-service training/staff development v Maintain knowledge of current TR/RT trends Vv Enhance professional competence/additional credentials Vv Enhance professional competence ~. ‘Support the development of evidence-based practices 4 Adhere to professional standards of practice and code of ethics Cy }0_| Participate in quality improvement process [lv 1_| Participate in agency/professional committees ‘Assessment 12its 12 | Request/secure referrals/orders v 13__| Obtain/review pertinent information Iv vv v ole 14 | Select/develop assessment methods/setting 15__| Establish therapeutic relationship 16 | Conduct assessments 17_| Analyze/interpret results | 18 | Integrate/record/disseminate results IPlan Interventions and/or Programs 34] 5 | na 19 _| Discuss results of assessment 20_| Develop/document intervention plan i 21_| Develop/select interventions/approaches v 22 _| Develop/select protocols yo 23_| Utilize activity/task analysis vi 24 | Select adaptations/modifications/assistive technology v Implement Interventions and/or Programs 3 [4 [5 | na 25 | Explain the purpose/outcomes of the intervention/program Vv 26 _| Implement individual/group sessions(s) Vv 27 _| Use leadership/facilitation/adaption techniques v 28 | Monitor/address safety MI 29 | Observe for response to intervention/program v 30 _| Monitor effectiveness of intervention/program Vv Evaluate Outcomes of the Interventions/Programs 3 [4/5 [na [31 Evaluate changes in functioning v [32 [Determine effectiveness of individual intervention plan v 33_| Revise individualized intervention plan v 34_| Evaluate for additional/alternative/discharge of services vy 35_| Determine effectiveness of protocols/programs Vv Document Intervention Services 31415 [na 36 | Document participation/adherence to intervention v4 37 _| Document behavioral observations v 38_| Document occurrences related to risk management vi 39 _| Document protocols/modalities vi 40 _| Document program effectiveness z v ‘Treatment Teams and/or Service Providers 3 [4 [5 [na 41_| Identify the treatment teanm/community partners 42_| Provide information to team/community partners y| L 43_| Communicate information v | 44_| Coordinate/integrate intervention plan 45_| Develop/provide collaborative services a ‘Develop and Maintain Programs 31415 [na 46_| Maintain equipment/supply inventory v 47_| Plan/eoordinate support services v 48__| Maintain program budget/expense records 49 | Develop/distribute schedules Vv 50_| Identify funding sources 51_| Conduct needs assessment am 52__| Conduct ongoing program evaluation 53_| Follow risk management practicesManaging TRIRT Services 3 [4 [5 [aa 34_| Comply with standards/regulations v 53_| Prepare/update written plan of operation v 56 | Confirm programs are consistent with agency mission v 57_| Recruit/train/educate/supervise/evaluate staff Cy 58_| Provide staff development/mentorship v 59_ | Develop/implement/maintain internship program v 60_| Prepare/implement/evaluate/monitor annual budget v 61_| Support research programs/projects iv 62_| Develop/conduct quality improvement plan v 63_| Write summary reports of TR/RT services v 64 _| Identify/obtain/manage supplemental funding Awareness and Advocacy 3 [4 [5 [na 65_| Establish/maintain network with organizations/advocates Vv 66 | Advocate for rights of person(s) served 67_| Provide education to the intemal/extemnal stakeholders Vv 68 | Promote marketing/public relations v. 69_| Monitor legislative/regulatory changes I v Part Two: Personal and Professional Development Criteria The Therapeutic Recreation Intern Demonstrates: 5 | na 1_| Positive Attitude v 2__| Enthusiasm v 3_| Self-confidence is ate 4 Empathy 5_| Flexibilit Vv 6 | Willingness to learn v 7 [Judgment v 8 [Initiative | > Respect and courtes} Mv 10_| Cooperation Vv 11_| Ability to evaluate personal strengths and weakness v 12_| Ability to accept constructive criticism Vv 13_| Professional dress according to setting v 14 | Work habits (timeliness, completeness, consistent quality of work vi 15_ | Planning and organizational skills (time management, vif management of space and materials) | 16 | Interpersonal relationships (with supervisor, staff, customers) Vv | 17 | Effective verbal communication skills (assertiveness, clarity, Vv | organization) 18 | Effective written communication (skills grammar, a spelling, legibility) 19 | Uses available computer 20 _| Use of medical terminology and abbreviations | 21_| Maintenance of professional boundaries (personal space, Vvrelationships, language) 22_| Ability to seek direct and indirect supervision 23_| Ability to accept direct and indirect supervision KIS] Part Three: Comments 1. In what areas does the intern excel? Sasha is VY proactive anol Lavery need te A5Kher to do Sometrninn \oecause she is trendy deine it. She Shows Arek Uunikerstouretire of The TR process and how to use it. She ig very Witting 4o learn ounct inpreve accepts cund Appees Feedtoack Lonsistenty. 2. In what areas does the intern need further development? Sasha ig working on Feeding Move Contidert 1 Yunning aVvorps and Larning processing SKiNIc. Date of Evaluation:_\®|\\ [19] as He Agency Supenisor Sls —— Pannen erviena an Student Siomane_ Sip Gorn