ࡱ> fgnotuvwgh{ #` qbjbj\.\. ʁ>D>D N1<Ou:)))t*a5455 ^t`t`t`t`t`t`t$wh#zt73a577t)t*' u@8887()t*^t87^t88[,^^t* ਮJ v8pJ^&^lEu<up^Jzq8"zL^z^85h6J8g6<66555tt8555u7777OOODeYOOOtxJ LOMA LINDA UNIVERSITY Department of Social Work and Social Ecology Educational Outcome Assessment - Clinical Concentration Year IV-E This form is due to your Field Faculty Liaison at the end of each quarter. The time sheet should be attached to this form. Student Name (print): FORMTEXT      Field Instructor:  FORMTEXT      Quarter: FORMTEXT      Date: FORMTEXT      Total Hours in Practicum: FORMTEXT       Assessment Instructions Using the practicum evaluation scale below, indicate the level of achievement accomplished by the student for each educational outcome. Practicum Evaluation Scale 1 Student shows no evidence of understanding the concept and/or demonstrating the skill.2 Student shows little evidence of understanding the concept and/or demonstrating the skill.3 Student shows some understanding of the concept and beginning to recognize in hindsight how it might have been applied in practice situations.4 Student understands the concept and applies the skill, but performance is uneven. Needs time and practice.5 Student understands the concept and applies the skill with consistency.N/A 1 No opportunity to develop this skill in this setting as of yet. Comment required for each N/A grade.N/A 2 Field Instructor does not have the evidence needed to make a judgment. Comment required for each N/A grade. Immediately contact the field faculty liaison if student is performing at level 1 on any educational outcome. Please be prepared to provide documented examples. Understands, Respects, and Integrates the Ethics and Values of the Social Work Profession12345NA1NA2Demonstrates respect for right of self determination within the framework of legal and ethical requirements. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Maintains appropriate guidelines for confidentiality. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Maintains appropriate boundaries, distinguishing professional relationships from personal relationships. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates the capacity to respect diverse issues of gender, race, religion, class, disability, and age. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Identifies ethical dilemmas as these arise and takes to supervision for discussion. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates use of professional judgment and conduct consonant with the values, ethics, legal, and multidimensional responsibilities of practice principles within a clinical CSW setting. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates understanding of mandated reporting laws and responsibilities. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Learning Objective II: Demonstrates Motivation in the Role of Learner12345NA1NA2Takes initiative to identify own learning needs. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates an ability to integrate new knowledge. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Actively participates by asking questions and volunteering relevant information while in supervision or other training experiences. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates ability to learn from a variety of sources (peers, other agency staff, field instructor, preceptors, consultants, Field Faculty, assigned readings.) FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates the integration of complex theories and research findings in developing his/her practice proficiency. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Evidences interest and takes advantage of opportunities for expanding his/her knowledge and skills for working with population groups and problem area FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates the capacity to evaluate his/her own practice in specific and meaningful ways. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Accepts and utilizes constructive criticism. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Acknowledges areas of strength. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Acknowledges areas of needed growth and development. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates ability to identify own values and the potential impact on treatment objectives. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Prepares for supervisory conferences. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Participates in educational planning and evaluation of his/her performance. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates ability to assess need for direction from field instructor and is able to operate independently when appropriate. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates familiarity with and how to access information (i.e. ICWA, ICPC, MEPA) and/or policies unique to CPS. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Learning Objective III: Demonstrates Knowledge of the Agency's Mission, Goals, Organizational Structure and Community Which is Served12345NA1NA2Demonstrates working knowledge of the practicum agency's mission, goals, policies, and procedures. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Identifies and understands the intra-agency organizational relationships, activities and its impact on provision of services.. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates knowledge, respect, and ability to work cooperatively with support staff in the practicum setting. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Collaborates appropriately with other professionals or as a member of a multi-disciplinary team to ensure integrated and comprehensive culturally sensitive resources and services to clients. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates competence in accessing and utilizing community resources that are appropriate for the population being served. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Identifies social policies, laws, practices, etc. that impact the client system or delivery of service. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Understands the principles of concurrent and permanency planning. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Understands the process of the legal system and the role of social workers and other professionals in relation to juvenile court. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Learning Objective IV: Demonstrates Responsible Work Management Skills12345NA1NA2Keeps accurate and up-to-date case records following agency policy including demonstrating basic skills in CWS/CMS. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Completes and submits comprehensive process recordings (written, audio or video, minimum of one per week.) FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Writes in a well organized, comprehensive, and concise manner, using appropriate grammar, spelling, and professional vocabulary. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Manages workload and prioritizes work assignments. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Complies with agreed upon field practicum hours, including responsibilities to client and agency site. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Writes legibly and thoroughly in all types of documentation. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates the ability to prepare written reports for court in a timely manner. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Aware of risk management issues and able to appropriately resolve potentially harmful situations. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Complies with contact requirements as mandated by program status. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Learning Objective V: Demonstrates Skill in Developing an Appropriate Case/Treatment Plan Based on the Biopsychosocial Assessment and Diagnosis (When Applicable.)12345NA1NA2Demonstrates competence in completing a culturally sensitive biopsychosocialspiritual history. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates basic knowledge of systems theory in work with clients. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates the critical thinking necessary to identify clients symptoms and behaviors which impact on CWS practice and service provisions. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates awareness of self and responds objectively and purposefully rather than out of own needs and personal reactions. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates an ability to integrate and apply multiple theoretical frameworks in assessing client's presenting problem, assessment, and intervention. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Student demonstrates a solid understanding of the multidimensional dynamics of physical and mental illness as these impact client systems (i.e., individuals, groups, households, families, and communities.) FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates capacity to elicit information, including facts, feelings, and goals from client and significant others. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates ability to identify and clarify the presenting problem(s) and underlying dynamics and issues relating to both to-home and out-of-home care. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates ability to assess client and/or family member at risk for suicide, homicide, child abuse, elder abuse, spousal abuse, substance abuse, etc. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates ability to identify the client's internal strengths and support systems. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates competence in completing comprehensive risk and safety assessment and having working knowledge of WIC300. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates the ability to identify the clients internal strengths and support systems as well as engage the client to do so. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Learning Objective VI: Demonstrates Awareness of Self and the Impact on the Helping Process.12345NA1NA2Shows ability to differentiate one's own feelings, values, attitudes, and behavior from those of the client. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates awareness of self and responds objectively and purposefully rather than out of own needs and personal reactions. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Constructively deals with conflict and stress within the therapeutic process and agency context. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Learning Objective VII: Student Demonstrates Skill in Managing and Maintaining the Intervention Process in CWS.12345NA1NA2Understands the dual responsibility of the child welfare caseworker to protect children and to provide services that support families as caregivers. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Recognizes signs and symptoms of substance abuse in children and adults while incorporating knowledge of individual, family, and cultural dynamics, and is able to assess its impact. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates knowledge of a range of practice intervention reflecting the continuum of social work practice: information and referral, advocacy, case management, crisis intervention, short term intervention, and long term intervention and on-going case reassessment. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates knowledge of pre-placement preventative services, placement services, reasonable services, and concurrent planning. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Formulates a specific intervention plan with the client on an ongoing basis that includes appropriate short term and/or long term goals. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates advanced clinical knowledge and skills through the differential selection and application of treatment modalities, techniques, and strategies appropriate to identified populations and presenting problems. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Effectively deals with client resistance engaging involuntary client and understanding of becoming a client in CWS. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Plans and implements appropriate termination process with clients. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Understands and uses verbal and non-verbal cues including: body positioning, eye contact, speech patterns, tone and volume of voice. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates an ability to use the following: a. open and closed questioning, encouraging, paraphrasing, reflecting, and summarizing.  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  b. reframing, partializing, prioritization, and focusing. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  c. clarification, interpretation, and use of silence. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  END OF QUARTER FIELD PRACTICUM STUDENT SELF EVALUATION What are the three most important skills you learned this quarter?  FORMTEXT       What three things do you want to improve next quarter?  FORMTEXT        How have you changed as a social worker as a result of your field experience this quarter?  FORMTEXT       What have you discovered about yourself as a social worker? Be specific with at least two examples.  FORMTEXT        What is your greatest strength as a learner?  FORMTEXT       What is your greatest challenge as a learner?  FORMTEXT       Discuss how your field instructor helped you develop as a social worker this quarter.  FORMTEXT       FIELD PRACTICUM SUMMARY Please provide a narrative summary of the student's progress. 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Description of performance strengths. Description of specific learning patterns or behaviors that affect student's performance adversely. Changes in the agency that may have affected the student's education experience. Plans for the following quarter. Other pertinent information.  FORMTEXT       Student response to evaluation:  FORMTEXT        Grade Suggestion:  FORMCHECKBOX  Student performed at or above acceptable performance levels  FORMCHECKBOX  Student performed below acceptable performance levels Date Field Faculty Contacted  FORMTEXT       Student would benefit from continued learning at this agency. Yes  FORMCHECKBOX  No  FORMCHECKBOX  Field Instructor Signature: Date:  I have read the above evaluation. 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