PHED 4970: Exercise ScienceINTERNSHIP EVALUATION FORM

Bemidji State University – Department of Human Performance, Sport, & Health

Student completes the following:

Student Name: / BSU ID#:
Date: / Semester/Year
[select one]SpringSummerFall
Email you use: / # of internship credits registered for:

Supervisor completes the following:

Name of person completing the evaluation: (Printed)
Practicum site: / Phone:
() -
Address: / Area:
City/State/Zip: / Email:
Mid-term evaluation
Final evaluation: Did the student complete a MINIMUM of 30 hours per credit? YES NO Comments:
Student’s Responsibilities
List the main responsibilities you delegated/exposed the student during the internship (list will expand as you type and hit ENTER)
Evaluation
Please use the following Rating Scale to evaluate the student intern on the criteria listed on the next page.
Leave comments if desired and/or applicable.
Rating Scale:
5 = Excellent; no additional work needed
4 = Good: fine tuning will result in excellence performance/skill level
3 = Acceptable/Adequate: performance/skill level will improve with additional practice/mentoring
2 = Below average: remedial help is needed to achieve an acceptable performance/skill level
1 = Major problems: special measures are/were needed to deal with the situation
0 = Not applicable or Unknown
Knowledgerelated toInternship Discipline/Area
Rating / Strengths / Weaknesses
Demonstrates growth and/or potential for growth in discipline/area
Academic Preparation/Knowledge
Rating / Strengths / Weaknesses
Human Anatomy & Physiology
Exercise Physiology
Biomechanics
Injury Care & Prevention
First Aid & Emergency Procedures
Interpersonal Skills
Rating / Strengths / Weaknesses
Compatibility with co-workers
Receptivity to feedback/suggestions
Ability to work in groups
Ability to relate to clients
Ability to motivate clients
Respect and acceptance of others
Accepting and non-judgmental
Relationship with clients
Intrapersonal Skills
Rating / Strengths / Weaknesses
Self-confidence
Ability to adjust to change
Problem solving skills
Positive attitude/optimistic
Ability to respond to work demands
Communication Skills
Rating / Strengths / Weaknesses
Oral
Written
Listening and responding
Professionalism/Work Performance
Rating / Strengths / Weaknesses
Promptness and dependability
Projects/Tasks completed on time
Quality of work
Willingness to assume responsibility
Planning and organizing skills
Ability to work with client needs
Time management skills
Dress/appearance
Personal conduct
Initiative/Interest
Rating / Strengths / Weaknesses
Enthusiasm/Interest
Willingness to ask questions
Self-motivation (initiative)
Creativity
Ability to offer ideas/assistance
Overall
Overall evaluation of the student: (check one) Excellent Good Adequate Poor Unsatisfactory
Additional Comments
Provide additional comments you have on the student and their practicum experience in this space:

Date:______NAME:______Title:

A final grade (“S” for satisfactory or “U” for unsatisfactory) is given upon fulfillment of the practicum and completion of this evaluation form. This COMPLETED evaluation form must be returned to B. Christina Kippenhan, as an attachment to an email to or by mail to: B. Christina Kippenhan;Dept. of Phys. Ed. Health & Sport; Bemidji State University; 1500 Birchmont Dr. NE # 29; Bemidji, MN 56601
Phone: 218-755-2076.

Last updated: 2013-09-04