Evaluation Tool for Child Life Interns

Student’s Name: ___ Ashlynn Petersen ______

Evaluator’s Name: ____Self Evaluation_____ Rotation: Pediatric Intervention Team Midterm

Evaluator’s Name: ___________________ Rotation: _____________________________

The evaluation of a child life intern is an assessment of demonstrated clinical skills and
knowledge base. The following document is designed to assess skills and knowledge base
reflective of the CLC Child Life Competencies and the Child Life Professional Certification
Examination Classification System. The intern will be evaluated by her/his supervisor(s) on
performance achieved during the internship, with opportunity for discussion related to
clinical skills/knowledge base and areas of recognized strength for maximized growth and
development.

The document is designed for the same tool to be utilized multiple times during the
internship so that progress across the continuum of the experience is easily discerned.
Space is included for the evaluator to make additional comments and define, when
indicated, necessary and specific action plans for successful achievement of competencies.
The rating levels of 0, 1 and 6 as defined below are shaded in grey as it is anticipated that
they will be used sparingly and after careful consideration and documentation of specific
performance examples.

Disclaimer:
Use of this tool is voluntary.  Application of and the results from the use of this tool are at
the discretion of the internship program. Results are not a guarantee of future
performance.
 Intern Initials: _AP_
Internship Session: _Fall 2018_

RATING DEFINITIONS

1. Not Acceptable
The intern does not perform this skill at a level acceptable for a beginning child life intern,
even when provided considerable assistance by clinical supervisor. If little or no improvement
is observed, intern may be asked to withdraw from the internship.

2. Below Standard
The intern requires significant assistance in order to perform the skill or behavior. The intern
is given multiple opportunities to build skills and is having difficulty integrating feedback and
improving skills. If little or no improvement is observed, intern may be asked to withdraw
from the internship.
• Assistance/Guidance: The intern performs this skill at a level comparable to that of
beginning child life intern when provided considerable assistance by clinical supervisor.
• % of Caseload: Clinical supervisor is unable to allow intern to function independently at
this task (0% of caseload).
• Amount of Follow-up Required: Follow-up is required with patients/families/staff by
clinical supervisor after nearly every time the intern performs this task.
• Initiative: Intern displays very little, if any, initiative towards performing this task.
• Ease of Performing Task: Intern’s apprehension around patients and families when
performing this task is consistent and apparent.

2. Standard Beginning Intern

The intern requires appropriate assistance in order to perform the skill or behavior, but is
demonstrating improvement in this area.
• Assistance/Guidance: The intern requires considerable assistance in order to perform the
skill or behavior, but is demonstrating improvement in this area.
• % of Caseload: Clinical supervisor is able to allow intern to function independently at this
task <25% of the time.
• Amount of Follow-up Required: Clinical supervisor is still observing and/or visually
present. Clinical supervisor finds it necessary to follow-up with patients/families/staff
after intern performs this task most—though not all—of the time.
• Initiative: Intern displays growing sense of initiative towards performing this task,
however is often prompted by clinical supervisor.
• Ease of Performing Task: Intern is beginning to display ease around patients and families.

3. Continued Improvement
The intern requires some assistance in order to perform the skill or behavior effectively most
of the time.
• Assistance/Guidance: The intern requires occasional assistance in order to perform the
skill or behavior effectively.
• % of Caseload: Clinical supervisor is providing regular guidance regarding prioritization
and skill set, however, allows intern to function independently 25-50% of the time when
performing this task.
• Amount of Follow-up Required: Intern takes direction and applies it appropriately.
Some follow-up is required with patients/families/staff by clinical supervisor when intern
performs this task.
• Initiative: Intern takes the initiative to perform this task more often; clinical supervisor
needs to prompt approximately half of the time.
• Ease of Performing Task: Intern’s ease around patients and families is growing, and it is
becoming apparent when performing this task.

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 Intern Initials: _AP_
Internship Session: _Fall 2018_

4. Increasing Independence
The intern takes initiative and is able to begin tasks independently the majority of the time.
• Assistance/Guidance: The intern requires very little assistance in order to perform the
skill or behavior effectively.
• % of Caseload: Intern begins to share responsibility of patient load (example: “splitting
the patient load”). Intern functions independently 50-75% of the time. Clinical supervisor
has to provide guidance regarding prioritization only occasionally.
• Amount of Follow-up Required: Intern takes direction and applies it appropriately. Very
little follow-up is required with patients/families/staff by clinical supervisor when intern
performs this task.
• Initiative: The intern takes initiative and is able to begin this task independently, most
often without prompting from the clinical supervisor.
• Ease of Performing Task: Intern’s ease around patients and families is consistent and
apparent in most interactions.

5. Job Entry
The intern is able to perform the skill or behavior effectively and independently. The intern
applies the skill in a manner expected of a child life intern ready to begin his/her first job as
a child life specialist.
• Assistance/ Guidance: The intern is able to perform this skill or behavior effectively and
independently—not requiring the assistance of the clinical supervisor. The intern applies
the skill in a manner expected of a child life intern ready to begin an entry level position
as a child life specialist.
• % of Caseload: Intern can assume most or all of the entire caseload of a child life
specialist (75-100%). Clinical supervisor very rarely provides guidance regarding
prioritization.
• Amount of Follow-up Required: Intern consistently interacts appropriately with
patients/families/staff. Clinical supervisor does not find it necessary to follow-up with
patients/families/staff after intern’s interactions.
• Initiative: Intern takes initiative and always begins tasks independently.
• Ease of Performing Task: Intern’s ease around patients and families is consistent and
apparent in nearly all interactions.

6. Exceeds Job Entry

The intern performs the skill or behavior at the level of a child life specialist with 1-2 years
experience.
• Assistance/Guidance: The intern performs this skill or behavior with an exceptional level
of expertise.
• % of Caseload: Intern can assume 100% of the child life specialist’s caseload and does not
require any guidance regarding prioritization of patient and family needs.
• Amount of Follow-up Required: Intern interacts with patients/families/staff
exceptionally well. No follow-up is required and patients/families/staff often comment
on how well the intern performed at this task.
• Initiative: Intern takes initiative to go above and beyond standard expectations, often
thinking often thinking of unique approaches to her/his work.
• Ease of Performing Task: Interns’ ease around patients and families is consistent and
apparent in all interactions and can even put others at ease by her/his presence.

N/A Not Applicable

The intern had no opportunity to demonstrate this skill or this skill does not apply in this
patient area.

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 Intern Initials: _AP_
Internship Session: _Fall 2018_

Domain I: Assessment
Task 1: Identify, obtain, and use
relevant data (e.g., health care,
family, child) regarding the child Stand Contin Increa
ard ued sing
and family to develop a Not Below Begin Impro Indep Excee Not
comprehensive assessment and Accep Stand ning veme enden Job ds Job Applic
initiate a plan of care table ard Intern nt ce Entry Entry able

A. Effectively interprets and

incorporates pertinent data into
0 1 2 3 4 5 6 N/A
developing a child life plan of
care
B. Uses developmentally appropriate
play as a primary tool in assessing
0 1 2 3 4 5 6 N/A
and meeting developmental and
psychosocial needs
C. Utilizes effective communication
skills to learn from children and
families and formulate patient- 0 1 2 3 4 5 6 N/A
and family-centered, culturally
appropriate goals
D. Prioritizes child life services based
on comprehensive analysis of the 0 1 2 3 4 5 6 N/A
needs of patients and families
Areas of strength and proposed action plan(s):
Midterm:
• When obtaining relevant data for creating a comprehensive assessment about patients and
families, I utilize a variety of tools such as play, speaking with family members, observing
body language, speaking with members of the healthcare team, looking at patient charts,
and pre-op phone calls.
• I am able to use play to assess and meet the developmental needs of children consistently
and effectively. (Ex: 2 year old with RAD on the inpatient unit, 3 year old in the SDC, 2 year
old in the ED)
• I am learning how to prioritize the needs of patients in the ED as I learn about new
diagnoses and procedures that kids might encounter. I also am adjusting to the multiple
different factors that are at play in the ED including wait times, how the patient got to the
ED, procedures, etc.
• I will continue to practice these skills in the different areas of the hospital where PIT
supports children and with practice will become more comfortable and confident.

No
Task 2: Identify developmental factors t Stand Contin Increa
Ac ard ued sing
and their implications regarding the ce Below Begin Impro Indep Excee Not
child’s health care experience in order pta Stand ning veme enden Job ds Job Applic
to plan appropriate interventions ble ard Intern nt ce Entry Entry able

A. Accurately assesses patients'

developmental levels, identifying 0 1 2 3 4 5 6 N/A
strengths and vulnerabilities

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 Intern Initials: _AP_
Internship Session: _Fall 2018_

B. Assesses the child's and family's

concept of illness, diagnosis, 0 1 2 3 4 5 6 N/A
procedure, or reason for visit
C. Utilizes knowledge of human growth
and development theory in
identifying relevant developmental 0 1 2 3 4 5 6 N/A
considerations for individual patients
and families
Areas of strength and proposed action plan(s):
Midterm:
• Based on my knowledge of development I am able to identify the developmental factors
that are at play and are important for specific children at different ages. I am able to utilize
this knowledge in my assessment and development of interventions for children.
• I am becoming more confident with remembering and utilizing my knowledge of healthcare
related developmental fears and implications for children to help assess their concept of
illness, diagnosis, procedure, or reason for visit.
• As I practice these skills and continue to apply my knowledge of development in practice, I
will become more and more confident and able to use these skills with ease.

Task 3: Identify psychosocial factors

(e.g., diversity, culture, spirituality,
family dynamics and structure,
coping styles, socioeconomic status) Stand Contin Increa
ard ued sing
and family-identified needs and Not Below Begin Impro Indep Excee Not
goals in order to provide patient- Accep Stand ning veme enden Job ds Job Applic
and family-centered care table ard Intern nt ce Entry Entry able

A. Integrates assessment of
psychosocial and contextual
factors in understanding children's 0 1 2 3 4 5 6 N/A
and families' adjustment and
behavior
B. Assesses key psychosocial and
contextual factors, identifying
strengths and vulnerabilities 0 1 2 3 4 5 6 N/A
relevant in developing a plan of
care
C. Assesses the meaning for the child
and family of the illness,
0 1 2 3 4 5 6 N/A
diagnosis, procedure, or reason
for visit

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 Intern Initials: _AP_
Internship Session: _Fall 2018_

Areas of strength and proposed action plan(s):

Midterm:
• In the various areas of the hospital, I have been able to see a variety of unique patients and
families and have been able to demonstrate my ability to assess and reflect about the
various psychosocial factors that we must consider to deliver family centered care. (Ex: 15
month old in ED’s mother, wife and son of adult patient)
• In the surgical area, I have had opportunity to assess the meaning of the reason for visit and
procedure for the child and family. I have been able to see this be done by Vicky asking
during introductions “what are you here for today?” And assessing what the patient says
from there. I have also been able to discuss this in more detail with patients in pre-op and
during preparation. This is a skill I want to continue to practice as I am not fully comfortable
with assessing this always and with how to respond.(Ex: 3 year old in SDC stating “I’m here
to get my eyes fixed”
• For the future, I need to work more on understanding and working directly with the patients
to assess what the meaning of illness, diagnosis, and procedure is for them.

Domain II: Intervention

Task 1: Provide psychosocially and

developmentally appropriate Stand Contin Increa
ard ued sing
support that is responsive to the Not Below Begin Impro Indep Excee Not
specific needs of children and Accep Stand ning veme enden Job ds Job Applic
families. table ard Intern nt ce Entry Entry able

A. Identifies goals and interventions

that reflect accurate assessment
of individual needs and respect 0 1 2 3 4 5 6 N/A
for diverse cultural and family
contexts
B. Adjusts goals and interventions as
needed to meet individual needs 0 1 2 3 4 5 6 N/A
and respect contextual factors
C. Coordinates child life
programming with
multidisciplinary and family goals 0 1 2 3 4 5 6 N/A
as well as medical treatment
plans and care giving schedules
Areas of strength and proposed action plan(s):
Midterm:
• After making an assessment, I am able to create ideas of a plan for intervention to meet the
needs of the patient and family. I am able to adjust my plan when needed based on the
child’s needs. (Ex: 2 year old patient with RAD)
• I have been able to coordinate with the multidisciplinary team including nursing, anesthesia,
pediatric hospitalists, surgeons, the behavioral health team, etc.

!6
 Intern Initials: _AP_
Internship Session: _Fall 2018_

Stand Contin Increa

ard ued sing
Task 2: Empower and collaborate Not Below Begin Impro Indep Excee Not
with children and families to Accep Stand ning veme enden Job ds Job Applic
develop and use advocacy skills table ard Intern nt ce Entry Entry able

A. Accurately assesses patients' and

families' strengths and
0 1 2 3 4 5 6 N/A
preferences for participating in
care and decision-making
B. Recognizes and facilitates
participation of patients and
families in ways that enhance 0 1 2 3 4 5 6 N/A
their sense of control and
independence
C. Communicates with patients and
families in ways that demonstrate
respect for and affirmation of 0 1 2 3 4 5 6 N/A
individual experiences,
preferences, and perspectives
Areas of strength and proposed action plan(s):
Midterm:
• I have had opportunities to assess patient and families preferences for participating in care
and decision making. In some instances I have wondered after if I assessed correctly and will
continue to practice this skill. (Ex: 17 year old wanting this dad to stay in waiting room for
IV, 15 month old patient’s mother during IV)
• I am always looking for ways to give patients control and independence in the various areas
of the hospital. (Ex: choosing scent for the mask, applying scent for the mask independently,
choosing toys, choosing if their parent will ride in the bed or walk to the OR, etc)
• I have had multiple opportunities to advocate or to observe advocacy for patients or
families. In these instances I have also been able to talk with or observe Vicky talking with
patients and families about how to advocate for their needs as well. (Ex: 12 year old needle
phobic patient,15 month old patient in ED to be held by his grandpa)

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 Intern Initials: _AP_
Internship Session: _Fall 2018_

Task 3: Provide educational

opportunities and resources that are Stand Contin Increa
ard ued sing
responsive to the needs of children Not Below Begin Impro Indep Excee Not
and families in order to promote Accep Stand ning veme enden Job ds Job Applic
learning and mastery table ard Intern nt ce Entry Entry able

A. Assesses knowledge level,

misconceptions, previous
0 1 2 3 4 5 6 N/A
experiences, and unique socio-
cultural and learning needs
B. In collaboration with family
members and professionals,
determines realistic goals and
0 1 2 3 4 5 6 N/A
objectives for learning and
identifies an action plan to
achieve these goals
C. Adjusts teaching to the
conditions, emotional states,
developmental abilities, and 0 1 2 3 4 5 6 N/A
cultural considerations of both the
child and family
Areas of strength and proposed action plan(s):
Midterm:
• As I learn the skills of psychological preparation and teaching, I am learning how to use my
knowledge of development and child friendly language to guide my teaching and resources.
• Most opportunities for teaching for me so far have been in the surgical area involving pre-op
teaching and preparation.
• While I not have direct examples of this, I am confident in my ability to adjust teaching
based on the patient and families needs. I am able to do this in other scenarios and skill
areas so I am confident that I could adjust teaching and preparation based on child’s stress,
developmental level, etc.
• I will continue to practice these skills in the surgical area and in other areas of the hospital
as opportunities arise. I will also create my own pre-surgical preparation book to use as an
educational material.

Task 4: Facilitate preparation (e.g.,

psychological, educational) for
challenging situations with children Stand Contin Increa
ard ued sing
and families in order to minimize Not Below Begin Impro Indep Excee Not
fear and anxiety and to promote Accep Stand ning veme enden Job ds Job Applic
mastery of their experience table ard Intern nt ce Entry Entry able

A. Engages in ongoing assessment of

potential stressors, recognizing
0 1 2 3 4 5 6 N/A
and responding to individual cues
communicated by child and family

!8
 Intern Initials: _AP_
Internship Session: _Fall 2018_

B. Adjusts preparation approach to

the conditions, emotional states,
developmental abilities, and 0 1 2 3 4 5 6 N/A
cultural considerations of both the
child and family
C. Uses developmentally appropriate
and medically accurate teaching
aids, preparation techniques, and
terminology so that the child's and 0 1 2 3 4 5 6 N/A
family's knowledge is increased
and emotional needs are
supported
D. Facilitates planning, rehearsal and
implementation of coping 0 1 2 3 4 5 6 N/A
strategies as part of preparation
Areas of strength and proposed action plan(s):
Midterm:
• Coming into this internship, I had little experience with preparation. Since the start, I have
been able to practice preparation in the surgical area with multiple different pre-op
patients. I have been able to observe preparation and independently prepare patients. (Ex:
observing preparation for a 15 month old’s ear tube surgery, observing preparation for an 8
year olds ear tube surgery, preparing a three year old for eye muscle surgery, preparing a 17
year old for knee surgery)
• I will continue to practice preparation in the surgical area as well as other areas of the
hospital. I will be able to engage in pre-op phone calls in which I can prepare patients for
some of what to expect and answer some of their psychosocial or developmentally related
questions.
• I will also create a pre surgical preparation book as part of my goals that will help me in
practicing these skill areas.

Task 5: Facilitate the development

of coping strategies for children
and families (e.g., pain
management, Positioning for
Comfort®, distraction, alternative Stand Contin Increa
ard ued sing
focus, guided imagery, child Not Below Begin Impro Indep Excee Not
participation) in order to minimize Accep Stand ning veme enden Job ds Job Applic
distress and promote empowerment table ard Intern nt ce Entry Entry able

A. Accurately assesses children's and

families' distress and coping levels 0 1 2 3 4 5 6 N/A
and responses
B. Utilizes effective techniques to
aid child and/or parent coping
during procedures or stressful
events with appropriate 0 1 2 3 4 5 6 N/A
consideration given to
developmental level and
emotional state

!9
 Intern Initials: _AP_
Internship Session: _Fall 2018_

C. Utilizes appropriate psychological

0 1 2 3 4 5 6 N/A
pain management strategies
D. Supports parents to be present
and provide support to their child 0 1 2 3 4 5 6 N/A
during stressful events
E. Facilitates opportunities for play
and other developmentally
appropriate activities to decrease 0 1 2 3 4 5 6 N/A
distress and increase effective
coping
F. Plans and implements activities to
aid immediate and long term 0 1 2 3 4 5 6 N/A
coping and adjustment
Areas of strength and proposed action plan(s):
Midterm:
• I have been able to observe Vicky supporting patients during multiple procedures and
stressful situations. (Ex: nerve block, femur splinting)
• I have also been able to support patients during procedures utilizing developmentally
appropriate pain management techniques, coping techniques, and distraction for a variety
of procedures. As I become more independent, I will continue to support patients and
families during procedures and stressful situations (Ex: anesthesia induction, IV start,
laceration repair, breathing treatment, nasal and throat swabs)
• I have become more and more comfortable with support parents to be present to support
their child. I have learned to be comfortable with taking a step back when the parent’s
support is what is working for the child and family.

Task 6: Facilitate play (e.g.,

recreational, health care,
therapeutic) and familiar life
experiences in order to encourage Stand Contin Increa
ard ued sing
expression, process information, Not Below Begin Impro Indep Excee Not
and promote development and Accep Stand ning veme enden Job ds Job Applic
normalization table ard Intern nt ce Entry Entry able

A. Identifies goals for play activities

based on individual assessment of
children's conditions and 0 1 2 3 4 5 6 N/A
developmental and psychosocial
needs
B. Facilitates opportunities for
therapeutic play that increase
0 1 2 3 4 5 6 N/A
children's mastery and coping with
health care experiences
C. Facilitates opportunities for play
that support individual 0 1 2 3 4 5 6 N/A
developmental needs and tasks

!10
 Intern Initials: _AP_
Internship Session: _Fall 2018_

D. Creates adaptive environments

and activities for children whose
0 1 2 3 4 5 6 N/A
access is restricted by a specific
diagnosis or condition
Areas of strength and proposed action plan(s):
Midterm:
• Normalization and facilitation of play are two of the skills that I have felt comfortable with
coming into this internship. Through play interactions with patients in all areas of the
hospital, I have been able to build quick therapeutic relationships with patients in which I
am able to assist in meeting their needs during their time at the hospital. (Ex: 3 year old in
the surgical center, 15 month old in ED, bubbles with patient in the ED with a femur
fracture)
• I have been able to create adaptive environments for children by providing play materials to
patients who cannot leave their room due to precautions, or who will be staying in one room
due to being in pre-op or the ED

Task 7: Evaluate and document

assessments, goals, interventions, Stand Contin Increa
ard ued sing
outcomes, and significant events in Not Below Begin Impro Indep Excee Not
order to communicate and modify Accep Stand ning veme enden Job ds Job Applic
care plans as necessary table ard Intern nt ce Entry Entry able

A. Evaluates effectiveness of
interventions based on outcomes
0 1 2 3 4 5 6 N/A
achieved and adjusts plan in
response
B. Documents concisely, objectively,
and accurately in the child's
medical record, including
0 1 2 3 4 5 6 N/A
developmental and psychosocial
issues pertinent to the plan of
care
Areas of strength and proposed action plan(s):
Midterm:
• I have found myself to be reflective in the moment and after the fact when evaluating my
assessments and interventions with patients. When communicating with Vicky about
assessments or interventions, i have been thorough in explaining what happened, giving the
outcomes, and then reflecting about my thoughts. (Ex: 17 year old knee surgery assessing if
patient was anxious about surgery or not, 15 month old patient and his mother during IV
start)
• While I understand the basics of documentation from my previous experience, I am still
adjusting to the different styles of documentation at Emerson. As I learn the programming
and the language used, I will adjust my previous knowledge of documentation to fit the
needs of documentation at Emerson

!11
 Intern Initials: _AP_
Internship Session: _Fall 2018_

Domain III: Professional Responsibility

Task 1: Maintain professional

standards of practice through Stand Contin Increa
ard ued sing
adherence to established ethical Not Below Begin Impro Indep Excee Not
guidelines in order to provide Accep Stand ning veme enden Job ds Job Applic
respectful and competent care table ard Intern nt ce Entry Entry able

A. Follows medical orders, infection

control, safety procedures,
0 1 2 3 4 5 6 N/A
privacy and confidentiality and all
other policies of the setting
B. Establishes and maintains
appropriate therapeutic
relationships and professional 0 1 2 3 4 5 6 N/A
boundaries among patients,
families and staff
C. Identifies relevant ethical
concerns and participates in
0 1 2 3 4 5 6 N/A
analysis of ethical issues to guide
practice
Areas of strength and proposed action plan(s):
Midterm:
• I am comfortable with my ability to follow infection control and safety procedures as well as
privacy and confidentiality.
• I have been able to establish appropriate therapeutic relationships with patients and
families during my experiences. (Ex: 3 year old in surgical area)
• I have found myself being very reflective to ethical issues this semester. Ex: working with
BHE patients (identifying what is and is not ethically in our scope of practice) and holding
down patients for procedures with the 12 year old patient who was needle phobic

Task 2: Promote professional

relationships (e.g., child life team,
interdisciplinary teams, community
resources) in order to enhance
communication and collaboration, Stand Contin Increa
ard ued sing
foster patient- and family-centered Not Below Begin Impro Indep Excee Not
care, and maximize positive Accep Stand ning veme enden Job ds Job Applic
outcomes table ard Intern nt ce Entry Entry able

A. Collaborates with family members

and professionals to integrate
0 1 2 3 4 5 6 N/A
interdisciplinary and family goals
into child life services

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 Intern Initials: _AP_
Internship Session: _Fall 2018_

B. Communicates effectively with

team members through case
conferences, rounds, and other
0 1 2 3 4 5 6 N/A
informal and formal contacts
pertinent to the needs of the
child and family
C. Recommends referrals when the
needs of the child and family are
0 1 2 3 4 5 6 N/A
beyond the scope of child life
practice
Areas of strength and proposed action plan(s):
Midterm:
• When at all possible, I try to collaborate with the family members to learn their goals and
needs. I am becoming more comfortable with the medical team to collaborate with them as
well
• I have been able to practice communicating with team members when passing off
information about patients after anesthesia induction to the PACU nursing team.
• I have not yet had opportunities at Emerson to place referrals when patient and family
needs are outside of the scope of child life. However, at my last placement, I did have
opportunities for this, and my final evaluation score for this section was a 3.

Task 3: Educate staff, students,

volunteers, and the community in
order to promote greater awareness Stand Contin Increa
ard ued sing
of the needs of children and Not Below Begin Impro Indep Excee Not
families as well as the child life Accep Stand ning veme enden Job ds Job Applic
profession table ard Intern nt ce Entry Entry able

A. Provides comprehensive volunteer

orientation in their assigned area 0 1 2 3 4 5 6 N/A
and to the child life program

B. Delegates volunteer duties and

assignments effectively, matching
volunteer ability to complexity of 0 1 2 3 4 5 6 N/A
task and communicating
expectations and roles clearly
C. Participates in giving and
receiving volunteer feedback in a 0 1 2 3 4 5 6 N/A
constructive manner
D. Demonstrates effective advocacy
for psychosocial issues and the 0 1 2 3 4 5 6 N/A
child life profession
E. Applies child life knowledge and
evidence-based practice to
contribute to the education and 0 1 2 3 4 5 6 N/A
awareness of others within the
setting and community

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 Intern Initials: _AP_
Internship Session: _Fall 2018_

F. Communicates information
effectively, integrating basic
concepts of public speaking and 0 1 2 3 4 5 6 N/A
teaching methods appropriate to
subject matter and audience
Areas of strength and proposed action plan(s):
Midterm:
• I have not had opportunities to orient volunteers given that this is out of the child life scope
at Emerson. However, I did get to work with some volunteers at the Verrill Farm event.
• At the Verrill Farm event, I also was able to do some community education as I spoke to the
community about Emerson, the PIT, and the coping kits program.
• I plan to continue practicing these skills through my third goal of staff education and
program development.

Task 4: Recognize and document

administrative responsibilities (e.g.,
quality improvement, staffing, and Stand Contin Increa
ard ued sing
resource allocation, policies, and Not Below Begin Impro Indep Excee Not
program evaluation) in order to Accep Stand ning veme enden Job ds Job Applic
ensure quality services table ard Intern nt ce Entry Entry able

A. Organizes and manages time

effectively, balancing direct and
0 1 2 3 4 5 6 N/A
indirect care responsibilities
appropriately
B. Maintains supplies and equipment
with attention to budgetary 0 1 2 3 4 5 6 N/A
constraints
C. Collects, analyzes and reports
accurate and pertinent data in a 0 1 2 3 4 5 6 N/A
timely manner

D. Provides feedback relevant to

continuing program improvement,
0 1 2 3 4 5 6 N/A
identifying opportunities and
needs to promote positive change

!14
 Intern Initials: _AP_
Internship Session: _Fall 2018_

Areas of strength and proposed action plan(s):

Midterm:
• I have had opportunities frequently to manage supplies and equipment when filling coping
kits. I have realized how much goes into ordering, storing, organizing, filling, and giving out
coping kits. I have also been able to see some of the budgetary information.
• When filling coping kits, I record data of how many coping kits are filled of each bag, in
each area. This type of data helps to see how many patients in each age group are coming
in.
• I have been able to effectively manage my time around direct and indirect care. Given
patient population, there is typically time where there is no patients which allows time for
administrative and indirect patient care tasks. During busier patient care times, I am
learning to manage my time effectively to make sure I am able to meet my goals in the
amount of time I have, with medical staff coming in and out to do their jobs as well. (Ex:
pre-op teaching)

Task 5: Engage in continuing

education (e.g., educational
opportunities, relevant medical Stand Contin Increa
ard ued sing
information, technology, research & Not Below Begin Impro Indep Excee Not
literature) in order to promote Accep Stand ning veme enden Job ds Job Applic
professional development table ard Intern nt ce Entry Entry able

A. Participates actively in
educational offerings throughout
the internship, demonstrating 0 1 2 3 4 5 6 N/A
critical thinking skills and insight
into application in practice
B. Uses current developmental
theory and research to guide
assessment of and identify 0 1 2 3 4 5 6 N/A
rationale for child life plan of
care
C. Identifies personal learning needs
and develops effective learning
0 1 2 3 4 5 6 N/A
plans, accessing available
resources
Areas of strength and proposed action plan(s):
Midterm:
• I was able to attend Schwartz rounds as an educational and reflective opportunity. This
allowed me to reflect and think critically about the case presented and the staff responses
• I have been able to identify some personal learning needs around supervision such as my
preferred feedback style when doing preparation with a patient. I was able to talk to Vicky
about this learning need and how well it worked for me. I identified her feedback style
during interactions with patients of asking questions that provide me with hints, but do not
take away my lead with the patient. (Ex: asking “So how will x get to the OR?” As a
reminder for me to prepare the patient about riding in his bed)
• I have also identified that there are so many pieces of preparation to remember. To meet
my own needs I have made a plan to make a cheat sheet of important things to remember
that I can utilize during my preparations.

!15
 Intern Initials: _AP_
Internship Session: _Fall 2018_

PROFESSIONAL SKILLS

KEY: 1=Unacceptable performance

2=Meets expectations
3=Outstanding performance

1 2 3
Reflective Practice      
Recognizes and demonstrates willingness to explore how personal challenges,   x   
learning needs, cultural and personal beliefs impact professional practice.
Engages in self-reflective practice, demonstrating realistic and critical     x 
thinking regarding own performance, and incorporates insights into practice.
Engagement in Supervision      
Readily accepts and integrates supervision and feedback from supervisor and   x   
other members of health care team.
Seeks support from mentors, peers, and supervisors.   x  
Contacts both clinical and academic supervisors in a timely manner when     x
absences are necessary or other concerns arise so they may be addressed.
Initiative      
Is motivated to learn.     x 
Follows through on specific assignments and tasks.   x   
Accepts responsibility and demonstrates initiative in work.    x  
Professional Presentation of Self      
Maintains a positive attitude, is tactful, and considerate.   x  
Demonstrates adaptability and flexibility in the health care environment.   x   
Remains calm in stressful situations.      x
Demonstrates respect for others’ points of view.   x  
Practices careful attention to verbal and written communication and to   x   
personal appearance.
Maintains confidentiality of children, families, and staff in and out of the    x  
health care setting.
Time Management      
Completes site assignments on time.   x   
Attends meetings and other scheduled responsibilities on time.   x   
Adheres to work hours and schedule.   x  

!16
 Intern Initials: _AP_
Internship Session: _Fall 2018_

EVALUATION OF CORE ASSIGNMENTS

Note: Additional lines are included for other core assignments to be added as appropriate to individual
internship programs.

KEY: 1=Unacceptable performance

2=Meets expectations
3=Outstanding performance
1 2 3

Journal x

Midterm Evaluation Reviewed & Discussed with Supervisor:

Rotation: ____________________________________ Date: _________________________

Supervisor Signature: __________________________ Intern Signature:

_____________________________

Wheelock/BU Academic Supervisor Signature:_________________________________________

Additional Comments:

Final Evaluation Reviewed & Discussed with Supervisor:

Rotation: ____________________________________ Date: _________________________

Supervisor Signature: __________________________ Intern Signature:

_____________________________

Wheelock/BU Academic Supervisor Signature:_________________________________________

Additional Comments:
!17