University of Kentucky Division of Communication Disorders

CD 657Mid-term and Final Practicum Evaluation Form

Student______

Instructor______

Facility______

1st Half Semester: Grades PW______Clinic______Date ______

2nd Half Semester: Grades PW______Clinic______Date______

FINAL GRADE (4 grades averaged) ______

I. PROFESSIONAL BEHAVIORS

Using the following scale, circle the letters that best describe the student’s professional behaviors.

SA Strongly agree

A Agree

DDisagree

SDStrongly disagree

PROFESSIONAL QUALITIES
  1. Is punctual and dependable.
/

SA A D SD

  1. Wears attire that meets the expectations of the practice setting.
/

SA A D SD

  1. Demonstrates initiative for increasing own skills in all areas of therapy and theory.
/

SA A D SD

  1. Follows the policies and procedures of the practice settings.
/

SA A D SD

  1. Adapts to change.
/

SA A D SD

PROFESSIONAL BEHAVIOR WITH OTHERS
  1. Maintains confidentiality.
/

SA A D SD

  1. Accepts supervision without defensiveness.
/

SA A D SD

  1. Maintains productive working relationships with patients, families, facility staff, co-workers, etc.
/

SA A D SD

  1. Treats others with dignity and respect.
/

SA A D SD

  1. Demonstrates behaviors that contribute to positive work environment
/

SA A D SD

  1. Manages conflict in constructive way.
/

SA A D SD

  1. Presents disagreements in a straightforward, calm, and professional manner.
/

SA A D SD

SAFETY
  1. Maintains safe working environment.
/

SA A D SD

  1. Observes health and safety regulations.
/

SA A D SD

  1. Recognizes physiological and psychological changes in patients and adjusts treatment accordingly.
/

SA A D SD

  1. Requests assistance when necessary.
/

SA A D SD

  1. Uses acceptable techniques for safe handling of patients.
/

SA A D SD

II. DIAGNOSTIC AND INTERVENTION SKILLS

Using the following scale, circle the letters that best describe the student’s diagnostic and intervention skills.

Scale:

HP Demonstrates high performance level with minimal supervision and guidance.

AMS Demonstrates acceptable performance level with moderate support and guidance.

AESDemonstrates acceptable performance with extensive support and guidance.

UDemonstrates unacceptable performance; unresponsive and/or unable to make changes given extensive, specific support and guidance.

DIAGNOSTIC SKILLS

  1. Administers and scores tests appropriately.
/

HP AMS AES U

  1. Thoroughly reviews clients’ folders.
/

HP AMS AES U

  1. Selects appropriate tests and materials.
/

HP AMS AES U

  1. Interprets diagnostic information accurately.
/

HP AMS AES U

  1. Develops functional recommendations.
/ HP AMS AES U
  1. Demonstrates skills in clinical observation.
/ HP AMS AES U
  1. Reports information accurately & appropriately to instructors, clients, families, and staff.
/ HP AMS AES U
  1. Assures that appropriate forms are complete.
/ HP AMS AES U
  1. Exhibits skillful interaction with client/family.
/ HP AMS AES U

INTERVENTION SKILLS

  1. Discriminates correct/incorrect responses.
/

HP AMS AES U

  1. Prepares for intervention sessions.
/

HP AMS AES U

  1. Selects goals/objectives that are based on interpretation of diagnostic information and knowledge of theory.
/

HP AMS AES U

  1. Initiates therapy at correct level of difficulty (i.e. at instructional level not frustration or independent levels).
/

HP AMS AES U

  1. Moves to next appropriate level when client’s performance indicates readiness.
/ HP AMS AES U
  1. Selects appropriate intervention strategies, materials, and equipment.
/ HP AMS AES U
  1. Uses time efficiently.
/ HP AMS AES U
  1. Obtains appropriate rate of response in treatment sessions.
/ HP AMS AES U
  1. Reinforces effectively.
/ HP AMS AES U
  1. Modifies plans as needed.
/ HP AMS AES U
  1. Responds to client/family needs and motivates to improve.
/

HP AMS AES U

  1. Successfully uses behavior management techniques.
/

HP AMS AES U

DOCUMENTATION

  1. Documents according to guidelines and format required by the setting.
/ HP AMS AES U
  1. Thoroughly completes paperwork and other assignments.
/ HP AMS AES U
  1. Completes documents on time.
/ HP AMS AES U
  1. Uses relevant information.
/ HP AMS AES U
  1. Uses appropriate grammar and spelling.
/

HP AMS AES U

  1. Uses professional language.
/

HP AMS AES U

III. Areas of Strength

IV. Areas for Growth

The instructor and student are to sign this form at the mid-term meeting.

Student:______Date: ______

Instructor: ______Date: ______

The instructor and student are to sign this form at the final meeting.

Student:______Date: ______

Instructor: ______Date: ______