Name Degree Licensure Address Work Phone Cell Agency Agency Address City State Zip Code Are you interested in a BSW or MSW student? BSW MSW Either Both Unsure Has your agency had a social work student intern before? Yes No How many students are you interested in? 1 2 3 4 5 Please attach a resume and return to: Donna Parker, P.O. Box 2460, State Univ., AR 72467 2017-2018 EVALUATION OF FIELD PROGRAM BY AGENCY FIELD Advanced
Q23 Support in the development of autonomy SD (1) D (2) A (3) SA (4) NA (5) Q24 I was satisfied with this agency SD (1) D (2) A (3) SA (4) NA (5) Q25 If you answered D, SD, or NA for any statement please briefly explain in the box provided Q26 Please provide any comments or suggestions in the box provided below. Please provide your name in the box provided Please provide the date in which you completed this evaluation in the box provided below. Thank you for participating in the 2017-2018 Field Faculty Liaison Evaluation of Agency Field Supervisor & Field Agency.
Q10 Overall, was an effective field supervisor SD (1) D (2) A (3) SA (4) NA (5) Q11 If you answered D, SD, or NA for any statement please briefly explain in the box provided below. Q12 Please provide any comments or suggestions in the box provided below. This Field Agency Provided: Q13 Experiences to work with clients with diverse SD (1) D (2) A (3) SA (4) NA (5) Q14 Access to vulnerable populations(e.g., children, elders, homeless, poor) SD (1) D (2) A (3) SA (4) NA (5) Q15 Opportunities for application of social work values and ethics SD (1) D (2) A (3) SA (4) NA (5) Q16 Opportunities to develop cultural competencies SD (1) D (2) A (3) SA (4) NA (5)
In this section of the Learning Agreement, students should identify the tasks and/or activities that will enable them to demonstrate the objectives of the specific competencies. Rating 1 – Consistently fails to meet expectations 2 – Occasionally meets expectations 3 – Meets Expectations 4 – Occasionally exceeds expectations 5 – Consistently exceeds expectations 6 – N/A 1. Demonstrate Ethical and Professional Behavior Make ethical decisions by applying the standards of the NASW Code of Ethics Learning activity Final Outcomes/Evaluation -to be completed at conclusion of semester Rating Use reflection and self-regulation to manage personal values and maintain professionalism in practice situations Learning Activity Final Outcomes/Evaluation -to be completed at conclusion of semester Rating Demonstrate professional demeanor in behavior; appearance and oral, written and electronic communication Learning Activity Final Outcomes/Evaluation -to be completed at conclusion of semester Rating Use technology ethically and appropriately Learning Activity Final Outcomes/Evaluation -to be completed at conclusion of semester Rating Use guidance of supervision and consultation Learning Activity Outcomes/Evaluation -to be completed at conclusion of semester Rating
PROCESS RECORDING Number: ____________ DATE OF INTERVIEW: ________ Student Name: Client Pseudonym: Purpose and goal of interview: Setting description: (where and who present) DSM Diagnosis: Behaviors and symptoms observed consistent with diagnosis: Client background information: Interview/Content/Dialogue – Record verbal interaction, include statements, non-verbal observations and client’s responses Thoughts & Feelings Your internal reactions. Assessment & Skills Identify skills and interventions used. Assessment of the skills, strengths & limitations. Reference competency # Plan for next session and issues for consultation with supervisor