ࡱ> JLGHIOU]^   !` J-bjbj\\ =>>U50  %^{^{^{8{Z~0RX(Ys $h< nYnn<  rrrn^ rnrr:| ^ F +j^{̝. ڱ<0  8hJr9<u<<nnnn000J^{000^{ dR @   LOMA LINDA UNIVERSITY Department of Social Work EDUCATIONAL OUTCOME ASSESSMENT Foundation Year 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. 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 Motivation in the Role of Learner12345NA1NA2Takes initiative to identify own learning needs. 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 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 work with clients. 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 Appropriately seeks direction from field instructor as needed FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates ability to work independently when appropriate. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 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 and activities. 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 services to clients. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates the ability to access and utilize 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 Demonstrates Responsible Work Management Skills12345NA1NA2Prioritizes work assignments. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Complies with agreed upon field practicum hours. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Notifies field instructor of any schedule changes. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Keeps accurate and up-to-date case records following agency policy. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Completes and submits one process recording per week (written, audio or video.) FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Writes legibly and thoroughly in all types of documentation. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates Skill in Completing a Biopsychosocial History Utilizing a Systems Theory Framework.12345Demonstrates basic knowledge of systems theory in work with clients. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Applies knowledge of human differences in practice, i.e., cultural, ethnic, racial, religious, sexual orientation, socioeconomic, gender, disability, age, etc. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Applies knowledge and concepts of human growth and development in work with clients (physical, behavioral, emotional, social, and spiritual.) 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). 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 a Basic Range of Generalist Practice Skills and Interventions Reflecting the Continuum of Social Work Practice: Information and Referral, Advocacy, Case Management, Crisis Intervention, Short-Term Intervention and Long-Tern Intervention.12345NA1NA2Demonstrates an understanding of generalist practice with individuals. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates an understanding of generalist practice with families. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates an understanding of generalist practice with group and group process. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Demonstrates an understanding of generalist practice with communities and organizations. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Utilizes the intervention plan with the client on an ongoing basis, modifying short term and/or long term goals as needed. 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: Open and closed questioning, encouraging, paraphrasing, reflecting & summarizing. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Refraining, partializing, prioritization, and focusing. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX 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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