CSULB, DEPARTMENT OF SOCIAL WORK

UNDERGRADUATE SENIOR FIELD

LEARNING AGREEMENT

AND

MID-YEAR/FINAL EVALUATION

Student Name: / Faculty Liaison:
Agency Name: / Field Instructor:
E-MAIL:
Preceptor:
EMAIL:
Agency Address: / City and Zip Code:
Telephone and Area Code: / Fax Number:
THE AGENCY AND THE COMMUNITY
A. Agency Mission
B. Briefly describe your agency’s organizational structures:
C. Describe the agency services available to the community:
D. Briefly describe the community served by your agency and include:
  1. Geographic location and location of the agency within the community

  1. Ethnicity of the population served

  1. Socio-economic status of population

  1. Community’s need for resources

  1. Community’s perception of the agency

  1. Agencies to whom referrals are made

  1. What were the sources of your information in answering the above?

GENERAL TIME MANAGEMENT
  1. Days and hours in field placement

  1. Day, time, and length of individual field instruction

  1. Names(s) of preceptor(s) and/or contact person in field instructor’s absence

  1. Day and time of field seminar

  1. If the plan is for you to rotate or change programs in the agency, specify the time frame for the rotation

STUDENT’S EXPECTATIONS FOR SUPERVISION IN FIELD/INSTRUCTION
  1. Describe your expectations of the supervision process:

B. Describe your expectations of yourself in supervision:
C. Describe your expectations of your Field Instructor:
D. Describe your expectations of your Preceptor (if applicable):
FIELD INSTRUCTOR TEACHING PLAN
  1. Detail your expectations of your student in supervision

  1. How do you structure your weekly field instruction? Briefly describe your teaching plan. Please include how you plan to maximize diversity in your case assignments for each student.

  1. Describe your plan for use of a preceptor with your student (If applicable)
a.Role of preceptor
b. Detail your plan for monitoring and evaluating this experience

ORIENTATION CHECKLIST

Agency Overview

Review agency vision and mission/purpose statement

Tour of agency

Introductions to colleagues, support staff, and administration

Review organizational structure

Review the role of the agency in relation to the community and its resources

Review security and/or safety procedures and protocol

Agency Policies and Protocols

Review office procedures, supplies, and provisions

Review telephone and communication/computer utilization

Review intake/admissions/eligibility policy and procedures

Review internal communication

Review parking details

Review mileage policy

Review agency, department, and/or unit meeting schedule

Review client record/charting, policies and procedures

Review forms for documentation/accountability

Review regulations regarding confidentiality, release of information, etc.

Review client fees/payment schedule

Review client emergency protocol

Review child or elder abuse reporting protocol

Review work schedule, including lunch and breaks

Review information/referral policy

Review agency policy regarding harassment

Review agency policy regarding discrimination

Review agency policy regarding the Americans with Disabilities Act

Review agency policy regarding OSHA

Review agency policy regarding HIPAA

Field Instructor/Student Responsibilities

Review expectations for supervision and schedule

Review educationally based recording schedule

Review use of preceptor (if applicable)

Review plan for diversity/multi-cultural experiences

Review plan for monitoring of student hours (by both field instructor and student)

Review agency training or staff development opportunities

Review student’s personal safety issues and concerns and strategies to deal with them

SIGNATURES:

Field InstructorDate

StudentDate

SENIOR FIELD EVALUATION

INSTRUCTIONS FOR RATING INTERNS:

At the end of the Fall Semester, the level of skill development should be a minimum of 4-5 for all objectives. Please contact the liaisonbefore you submit this evaluation if your student falls below this expectation.

FALL SEMESTER

Number of hours completed:

If the student has not completed the required number of hours, please describe in detail the plan for these hours to be completed:

______

______

Student Strengths:

Areas Needing Improvement:

Field Instructor SignatureDate

Student SignatureDate

Student’s signature acknowledges that the student has participated in and has reviewed the evaluation.

SPRING SEMESTER

INSTRUCTIONS FOR RATING INTERNS:

At the end of the Spring Semester, the level of skill development should be a minimum of 7-8 for all objectives. Please contact the liaisonbefore you submit this evaluation if your student falls below this expectation.

Number of hours completed:

If the student has not completed the required number of hours, please describe in detail the plan for these hours to be completed:

______

______

Areas of strength and suggestions for further development:

Field Instructor SignatureDate

Student SignatureDate

Student’s signature acknowledges that the student has participated in and has reviewed the evaluation.

LEARNING AGREEMENT INSTRUCTIONS: The shaded area under each competency is the Learning Agreement Plan. The Student and Field Instructor will identify planned learning activities specific to the agency. The activities will provide opportunities to achieve each competency. A minimum of two activities must be listed for each competency. You may add more rows if needed.

Competency # 1. Student demonstrates generalist social work practice by working with all size systems: individuals, families, groups, communities and institutions.

LEARNING OPPORTUNITIES AND STUDENT ACTIVITIES TO ACHIEVE COMPETENCY #1

OBJECTIVES:

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Undergraduate Senior Field Evaluation/updated 8-21-09

Not at allModerately Very

CompetentCompetent Competent

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  1. Demonstrates the ability to effectively work with individuals in a person-in- environment context.

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  1. Demonstrates an understanding of group process and dynamics and works with a group to develop a system of mutual aid.

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  1. Demonstrates an understanding of the family system, and the ability to engage with that system in problem identification, goal setting and problem solving.

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  1. Demonstrates ability to assess a community's needs and engage in a change effort with community members in meeting those needs.

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Additional Comments: (Please note that additional comments are required for a score of 3 or less on any of the above skills areas and the liaison should be contacted.)

Competency # 2.Student demonstrates direct practice,assessment, preventive and interventive activities with individuals, families groups, communities and macro systems.

LEARNING OPPORTUNITIES AND STUDENT ACTIVITIES TO ACHIEVE COMPETENCY #2

OBJECTIVES:

Not at allModerately Very

CompetentCompetent Competent

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  1. Demonstrates ability to establish an effective client-worker relationship by use of rapport and trust-building.

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  1. Demonstrates the use of empathy.

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  1. Demonstrates the use of active learning.

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  1. Is able to start "where the client is."

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  1. Is able to engage the client in mutual problem identification.

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  1. Is able to engage the client in goal setting.

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  1. Demonstrates the ability to address and discuss issues of human diversity.

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  1. Is able to recognize client resistance and engage non-voluntary clients.

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  1. Continually assesses client progress and revises intervention plan accordingly.

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  1. Demonstrates knowledge of a range of practice interventions reflecting the continuum of social work practice which may include: information and referral, advocacy, case management, crisis intervention, short-term intervention and long term intervention.

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Additional Comments: (Please note that additional comments are required for a score of 3 or less on any of the above skills areas and the liaison should be contacted)

Competency # 3. Student has an understanding of the field work agency and the community and how to integrate classroom concepts and general principles in the operational process of agencies and communities.

LEARNING OPPORTUNITIES AND STUDENT ACTIVITIES TO ACHIEVE COMPETENCY #3

OBJECTIVES:

Not at allModerately Very

CompetentCompetent Competent

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  1. Is able to define the services and resources provided by the agency to its clients.

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  1. Demonstrates an understanding of the mission of the agency.

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  1. Demonstrates knowledge of the roles of other professionals in the practice setting.

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  1. Demonstrates an understanding of the populations served by the agency.

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  1. Demonstrates the ability to network appropriately with other provider agencies in the community to mobilize additional resources for clients.

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  1. Complies appropriately with agency policies, including: record keeping, preparation of reports, attendance and participation at meetings.

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Additional Comments: (Please note that additional comments are required for a score of 3 or less on any of the above skills areas and the liaison should be contacted)

Competency # 4. Student is able to test and develop practice skills with focus on the development of beginning generalist professional entry level competence.

LEARNING OPPORTUNITIES AND STUDENT ACTIVITIES TO ACHIEVE COMPETENCY #4

OBJECTIVES:

Not at allModerately Very

CompetentCompetent Competent

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  1. Shows ability to differentiate one's own feelings, values, attitudes and behavior from those of the client.

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  1. Evidences appropriate sensitivity, care and warmth with people.

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  1. Shows maturity in dealing with conflict and stress and the ability to use these emotions in a constructive manner.

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  1. Demonstrates appropriate assertive behavior.

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  1. Demonstrates appropriate use of authority.

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  1. Shares knowledge and information appropriately with other professions or as a member of a multi-disciplinary team.

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  1. Is able to integrate and apply knowledge and concepts of human growth and development, social policy development and social research in direct practice activities.

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Additional Comments: (Please note that additional comments are required for a score of 3 or less on any of the above skills areas and the liaison should be contacted)

Competency # 5. Student is able to integrate beginning knowledge of the professional values and ethics base into practice skills and use of self.

LEARNING OPPORTUNITIES AND STUDENT ACTIVITIES TO ACHIEVE COMPETENCY #5

OBJECTIVES:

Not at allModerately Very

CompetentCompetent Competent

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  1. Demonstrates a non-judgmental attitude.

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  1. Demonstrates respect for the right of self-determination.

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  1. Demonstrates respect for confidentiality.

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  1. Demonstrates a capacity to respect and value differences.

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  1. Is able to apply the NASW Code of Ethics in identifying ethical dilemmas and bringing them to supervision for discussion.

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F.Maintains appropriate boundaries, distinguishing a professional relationship from a personal relationship.

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  1. Exhibits a professional appearance and demeanor.

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  1. Demonstrates appropriate and professional time management in completing and submitting process recordings, keeping appointments and using time responsibly.

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Additional Comments: (Please note that additional comments are required for a score of 3 or less on any of the above skills areas and the liaison should be contacted)

1

Undergraduate Senior Field Evaluation/updated 8-21-09