Uo School Psychology Program

UO SCHOOL PSYCHOLOGY PROGRAM

STUDENT DATA SHEET FOR PORTFOLIO EVALUATION

Updated for May 2014

Complete this data sheet as part of your portfolio for the annual evaluation by faculty. Include the completed data sheet as the first page in your portfolio binder. It will be removed and entered into a spreadsheet file to allow the program director and student services coordinator access to basic individual and group data for our annual APA online report, TSPC and NASP approval reviews, internal improvement evaluation reports, etc.

Name: __________________________________________________________________

Gender: ____________

Race-Ethnicity (check all that apply):

o American Indian or Alaska Native

o Asian

o Black or African American

o Hispanic-Latino

o Native Hawaiian or other Pacific Islander

o White

Are you a Foreign National? ___ no ___ yes

Are you subject to the Americans with Disabilities Act? ___ no ___ yes

Program Enrolled: _______M.S. _______Ph.D.

What is your current year in the program? (e.g., 1st, 2nd, etc.) ____________

First Year Students Only:

Undergraduate Institution Name: ________________________________________________

Undergraduate Degree Year: ___________________________________________________

Undergraduate GPA (4.00 scale): ________________________________________________

GRE Information:

Verbal: __________

Quantitative: __________

Analytic Writing: __________

Advanced Psychology __________

Are you a respecialization* student? ___ no ___ yes

*Respecialization is when a student, who already holds a doctoral degree in an area of psychology, enrolls in another substantive area.

All student, please complete the following FOR THE 2013-2014 SCHOOL YEAR ONLY (June 15, 2013 – June 14, 2014):

Member of Professional or Research Society? ___ no ___ yes

Number of Scientific Publications during 2013-2014: _________

Include the number of books, book chapters, or articles in peer-reviewed professional/scientific journals of which you were an author or co-author. (Publications "in press," "under review," or "submitted" should not be counted here.)

Scientific Presentations during 2013-2014: __________

Include the number of workshops, oral presentations, and/or poster presentations at professional meetings of which you were an author or co-author.

Involved in leadership roles or activities in professional organizations? ___ no ___ yes

For example, roles in local, state/provincial, regional, or national organizations.

Presented a psychological topic to a lay or community audience? ___ no ___ yes

For example, gave an in-service to parents or community members.

_______ (yes/no) Were you involved in grant-supported research or training projects (e.g., training grant, worked as a GTF on a funded research project, etc.)?

_______ (yes/no) Were you involved in teaching or assisting in teaching a UO class (e.g., GTF for a class, or a supervised college teaching experience)?

_______ (yes/no) Indicate if you were involved in providing clinical or educational services through a practicum, GTF, or part-time job off campus

List your cumulative UO graduate GPA to date, from your unofficial UO transcript ___________

In the space below, list any “I” grades or grades lower than B- that appear on your UO graduate transcript, if you have any. Note the course number, course title, term, year.

Note: PhD students must complete page 3 of the Student Data Sheet.

UO SCHOOL PSYCHOLOGY PROGRAM

STUDENT DATA SHEET FOR PORTFOLIO EVALUATION

Updated for May, 2014

For PhD students only (data needed for APA online report):

1. Did you apply for internship for the 2013-2014 academic year? ___ no ___ yes

2. If yes, were you placed in an internship? ___ no ___ yes

If you are going on internship during 2014-2015, please answer the following:

1. Expected internship start date: ________

2. Expected internship end date: _________

3. Is internship APA-accredited? ___ no ___ yes

4. Name of Internship: ______________________

5. Is your internship ___ 1-year ___ 2-years

6. Is your internship ___ full-time ___ part-time

7. Is your internship funded? ___ no ___ yes

8. List how many practicum hours you have to date in the following categories as defined by the APPIC application for Psychology Internship (AAPI):

a. total assessment: __________

b. total intervention: ___________

c. total supervision: __________

d. total support (supporting activities, but not direct assessment or intervention): ________