Step 1 Form site ldentification student Name: Davie Poawe' oom‘ reorchotce Physical “TeraPy Company Name: ASHEN Home Cane company address. 2007 E. Copper. Roint De. Mtvidun, 1D B24 Company Phone:_2.08 -40]-4]% ematt_ One facilities Com . sudentpertornane DIV Lamotte , ppt Student supervisor preferred contact information: _GQQOB-TO3-Sto44- For supervisor: This student is currently enrolled in the: ‘College of Western Idaho Exercise and Health ‘Science Capstone course. As a part of this course ‘they must complete a minimum 45 hour | internship in @ field of their choice. As you are the ‘owner/employee who is working with the student you have ‘complete control over this internship. | ‘expect the student to work with you to set times and days they will be present to complete the required time at the internship, and to present themselves in a Professional manner at all times. if: ‘you have any issues with the student please contact me at timcurry@cwidaho.cc or 208-562-3077. Asa ‘Supervisor you will have control over a portion of the students grade and will be required to complete two more brie forms below at the mid-point and end of the internship. you have any questions, please contact me before signing below. By signing below ‘You are approving this student for an internship experience. ‘Supervisor Signature: For Stuclent: By signing below you aké acknowledging this form is correct for your internship. Please be aware that supervisor evaluation will be a part of your grade and has the power to end the internship at any time. If you have any concerns please discuss them with your supervisor and/or instructor before Starting the internship For student ~ affer discussing with your supervisor please briefly describe what your responsibilities will be at this internship: Fallow DA on Wer Home Herta visits. Gam Wnowkdgt on Coetan CHRELIEES Ror nest Common foe Ye geRiatzic gopuiaton. Obsoourg Wises followed by [eawning wht how... bert do Chaet Fags Pas tne visits.” Oueeall Wane Has help me dofeemine i€ His is 4 field tat ('m Wanting 4p porsve a capeee. <<,: Mid luati This form is to be filled at by the supervisor, and reviewed with student, when the student is. approximately 50% complete with their Internship hours. Please rate interns based on their performance at your facility, not their knowledge coming in unless itis causing serious Issues with expected internship duties = Completed:_Qah, (Ona scale below please rate your interns overall performance, please circle the rating 2 2 3 4 5 6 7 8 9 10 Worst Very Very | Very Below Abt Mode ve as voor | poor | P2*_| average | 8° | sverage | "coos ”| S204 | oS% ‘What are the top three areas they have done well in? 1 Danielle has always arnved as pahent appoinmmenss oneaa of me. : . . leasank to allot mypahenss , and is She aoe Pleas helping me mabe rye equi pmank. 3 panielie has a postrve attinude. She helps brigracn mg a vend CNeers up our pahents | ‘What are the top three areas where they could use improvement? 1. POSS\bI yesearch Physical Themey programs and mer mininun requ : : A ines 2 Researon diftererr areas of physical dermpy C pee sant ce) Y, 3% Look mr faicing a GRE prachce test which 15 on exam requutd for most ScnOUIS, ‘Are there any areas where you would like to see improvement for the second half of the internship? if 0, where? : ' Te est elle has been @n incredible cae oe erage: her as ghe chases Otter “her drtam OF becoming *® physical tmerpist. Once this evaluation has been discussed between supervisor and student please sign below and return to i memset rs smn Oia 9i End of i eval ‘This form is to be filled at by the supervisor, and reviewed with student, when the student Is complete with their internship hours. Please rate interns based on their ‘performance at your facility, not their knowtedge coming in unless itis causing serious issues with expected internship duties, Date: @4105 | a Hours completed: 45° On a scale below please rate your interns overall performance, please circle the rating 0 1 eileen + 3 é 7 & 9 io. Very Very | Very Below ‘Above | Moderately Very Worst | “Poor” | poor | P| averaye | Average | A rage | Good | 54 | Gory ( Best ‘What are the top three areas they have done well in? 1 Danis always ontime. She Shows op very picpoucde a work hard . Se ee veg aigh oban en we 4 e4 men . ere i * Sheic abwaye Very eins ama od Did the student imp eee) § ‘Are there areas where the student can use further improvement? Ifo, where?’ Dewi hus heen or Kad Lent Intern, Tyust would en Louray. hey do continue Chasing eter “ber diane 9 of bepena Gt. Lt 1s a, long road + becom AT, bur am wvomntel iy sry hos he a) Once this evaluation has been discussed between supervisor and student please sign below and return to instru . Student: mole Pall Supervisor Signature: g ). Veton alte