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SOCIAL WORK FIELD PLACEMENT PERFORMANCE EVALUATION FORMSocial Work 371/ 475/ 476 (Circle One)Name of StudentField InstructorTask Supervisor (if applicable)Field LiaisonAgencyNumber of Field Practicum Hours Completed to Date:Mid-term FinalThis evaluation form is for field instructors to provide feedback about Senior Social Work Majors intheir field placement. The activities/qualities you are assessing relate to the Social Work Program’srequired competencies as reflected in the Learning Contract completed at the beginning of thesemester. The evaluation should be a mutual process, with the student actively involved and signingthis form at the end.Rating Scale for Evaluation of Field Placement PerformanceINSTRUCTIONS: This evaluation instrument is designed to provide input from the field instructor tothe student and faculty liaison about the quality of the student’s performance in the field practicum. Thefaculty liaison is responsible for assigning the student’s semester grade based on this evaluation and onthe student’s participation in the field seminar. The field instructor should review the student’slearning contract before initiating the evaluation. Student performance should be rated based on theestablished criteria set forth in the Learning Contract. Evaluation of the student for SWK 371/ 475/ 476should be reflective of the student’s level of knowledge and skill.Instructions to Field Instructor: Please select only one score for each performance area.1 Unsatisfactory: The student has not yet developed this skill2 Needs Improvement: The student is beginning to recognize how it might be applied in apractice situation.3 Acceptable - The student demonstrates the skill at the expected level.4 Above average - Higher than average skills are applied fairly consistently.5 Outstanding- The skill is a fully integrated part of the student’s practice. Advanced skilllevel observed.NYC Not yet completed (only permissible at the mid-term)The agency field instructor is required to use the comment section of the evaluation to support and clarifyratings. Student and agency field instructor are expected to prepare the evaluation together, using thisopportunity to identify areas of mastery, as well as strategies for continued professional development.
COMPETENCY 1: INTERN DEMONSTRATES ETHICAL AND PROFESSIONALBEHAVIOR.CommentsMid-Term:Final:Total Score:/55Make ethical decisions by applying the standardsof the NASW Code of Ethics, relevant laws andregulations, models for ethical decision-making,ethical conduct of research, and additional codesof ethics as appropriate to context.Use reflection and self-regulations to managepersonal values and maintain professionalism inpractice situationDemonstrates professional demeanor in behaviorDemonstrates professional demeanor inappearanceDemonstrates professional demeanor in oralcommunicationDemonstrates professional demeanor in writtencommunicationDemonstrates professional demeanor in electroniccommunicationUses technology to facilitate practice outcomeethicallyUses technology to facilitate practice outcomesappropriately.Use supervision to guide professional judgmentand behavior.Uses consultation to guide professional judgmentand behavior5432154321
COMPETENCY 2: INTERN ENGAGES DIVERSITY AND DIFFERENCE IN PRACTICE.CommentsMid-Term:Final:Total Score:/30Student applies and communicates anunderstanding of the importance of diversity anddifference in shaping life experiences in practice atthe micro level.Student applies and communicates anunderstanding of the importance of diversity anddifference in shaping life experiences in practice atthe mezzo level.Student applies and communicates anunderstanding of the importance of diversity anddifference in shaping life experiences in practice atthe marco level.Students presents themselves as learners andengage clients and constituencies as experts of theirown experiences.Student applies self-awareness and self-regulationto manage the influence of personal biases inworking with diverse clients and constituencies.Student applies self-awareness and self-regulationto manage the influence of personal values inworking with diverse clients and constituencies.5432154321
COMPETENCY 3: INTERN ADVANCES HUMAN RIGHTS AND SOCIAL, ECONOMIC, ANDENVIRONMENTAL JUSTICE.CommentsMid-Term:Final:Total Score:/45Student applies understanding of social justice toadvocate for human rights at the:individual level of practice.Student applies understanding of social justice toadvocate for human rights at the:systems level of practice.Student applies understanding of economicjustice to advocate for human rights at the:individual level of practice.Student applies understanding of economicjustice to advocate for human rights at the: systemof practice.Students applies understanding of environmentaljustice to advocate for human rights at the:individual level of practice.Students applies understanding of environmentaljustice to advocate for human rights at the:systems level of practice.Student engaged in practice that advances:Social justice.Student engaged in practice that advances:Economic justice.Student engaged in practice that advances:Environmental justice5432154321
COMPETENCY 4: INTERN ENGAGES IN PRACTICE-INFORMED RESEARCH ANDRESEARCH-INFORMED PRACTICE.CommentsMid-Term:Final:Total Score:/15Use practice experience and theory to informscientific inquiry and research.Apply critical thinking to engage in analysis ofquantitative and qualitative research methods andresearch findings.Use and translate research evidence to inform andimprove practice, policy, and service delivery.5432154321
COMPETENCY 5: INTERN ENGAGES IN POLICY PRACTICE.CommentsMid-Term:Final:Total Score:/65Student identified social policy as it impacts well-being,service delivery and access to social services at the:Local levelStudent identified social policy as it impacts well-being,service delivery and access to social services at the:State levelStudent identified social policy as it impacts well-being,service delivery and access to social services at the:Federal levelStudent assesses how social welfare policies impact thedelivery of and access to social services.Student assesses how economic policies impact thedelivery and access to social services.Student applies critical thinking when analyzingpolicies that advance: Human rights and social justiceStudent applies critical thinking when analyzingpolicies that advance: Economic justiceStudent applies critical thinking when analyzingpolicies that advance: Environmental justiceStudent applies critical thinking when formulatingpolicies that advance: Human rights and social justiceStudents applies critical thinking when formulatingpolicies that advance: Economic justiceStudents will applies critical thinking whenformulating policies that advance: Environmentaljustice.Student applies critical thinking when advocating forpolicies that advance: Human rights and social justice:Economic justiceStudent applies critical thinking when advocating forpolicies that advance: Human rights and social justice:Environmental justice5432154321
COMPETENCY 6: INTERN ENGAGE WITH INDIVIDUALS, FAMILIES, GROUPS,ORGANIZATIONS, AND COMMUNITIES.CommentsMid-Term:Final:Total Score:/20Apply knowledge of human behavior and thesocial environment, person-in-environment, andother multidisciplinary theoretical frameworks toengage with clients and constituencies.Use empathy to effectively engage diverseclients and constituenciesUse reflection to effectively engage diverseclients and constituenciesUse interpersonal skills to effectively engagediverse clients and constituencies5432154321
COMPETENCY 7: INTERN ASSESSES INDIVIDUALS, FAMILIES, GROUPS,ORGANIZATIONS, AND COMMUNITIES.CommentsMid-Term:Final:Total Score:/35Collect and organize data, and apply criticalthinking to interpret information from clients andconstituencies.Apply knowledge of human behavior and thesocial environment, person-in-environment, andother multidisciplinary theoretical frameworks inthe analysis of assessment data from clients andconstituencies.Develop mutually agreed-on intervention goalsand objectives based on the critical assessment ofstrengths, needs, and challenges within clientsand constituencies.Develop mutually agreed-on intervention goalsand objectives based on the critical assessment ofneeds, and challenges within clients andconstituencies.Select appropriate intervention strategies based onthe assessment, research knowledge, and valuesand preferences ofclients and constituenciesSelect appropriate intervention strategies based onthe research knowledge, and values andpreferences ofclients and constituenciesSelect appropriate intervention strategies based onthe values and preferences ofclients and constituencies5432154321
COMPETENCY 8: INTERN INTERVENES WITH INDIVIDUALS, FAMILIES, GROUPS,ORGANIZATIONS, AND COMMUNITIES.CommentsMid-Term:Final:Total Score:/25Critically choose and implementinterventions to achieve practice goals andenhance capacities of clients and constituencies.Apply knowledge of human behavior and thesocial environment, person-in-environment, andother multidisciplinary theoretical frameworks ininterventions with clients and constituencies.Use inter-professional collaboration asappropriate to achieve beneficial practiceoutcomes.Negotiate, mediate, and advocate with and onbehalf of diverse clients and constituencies.Facilitate effective transitions and endings thatadvance mutually agreed-on goals.5432154321
COMPETENCY 9: INTERN EVALUATES PRACTICE WITH INDIVIDUALS, FAMILIES,GROUPS, ORGANIZATIONS, AND COMMUNITIESCommentsMid-Term:Final:Total Score:/50Select and use appropriate methods forevaluation of outcomes.Apply knowledge of human behavior and the socialenvironment, person-in-environment, and othermultidisciplinary theoretical frameworks in theevaluation of outcomes.Critically analyzes, monitor, and evaluateintervention and program processesCritically analyzes, monitor, and evaluateintervention and program outcomes.Critically monitors, interventions and programprocessesCritically monitors intervention and outcomes.Critically evaluate intervention and programoutcomes.Apply evaluation findings to improve practiceeffectiveness at the micro level.Apply evaluation findings to improve practiceeffectiveness at the mezzo levels.Apply evaluation findings to improve practiceeffectiveness at the macro levels.5432154321
MID-TERM EVALUATIONThe following parties have participated in this evaluation:Intern:Date:Field Instructor:Date:Task Supervisor (if applicable):Date:Field Director:Date:Total Score/340FINAL EVALUATIONThe following parties have participated in this evaluation:Intern:Date:Field Instructor:Date:Task Supervisor (if applicable):Date:Field Director:Date:Total Score/340
SOCIAL WORK FIELD PLACEMENT PERFORMANCE EVALUATION FORM Social Work 371/ 475/ 476 (Circle One) . The activities/qualities you are assessing relate to the Social Work Program's required competencies as reflected in the Learning Contract completed at the beginning of the
