Evaluation Tool for Child Life Interns

Student’s Name: Emily Allcrof

Evaluator’s Name: Carrie Byrne Rotation: Pre-op Holding/PACU/Mandell 3

Evaluator’s Name: Kate McCowan Rotation: Pre-op Holding/PACU/Mandell 3

The evaluation of a child life intern is an assessment of demonstrated clinical skills and knowledge base.
The following document is designed to assess skills and knowledge base reflective of the CLC Child Life
Competencies and the Child Life Professional Certification Examination Classification System. The
intern will be evaluated by her/his supervisor(s) on performance achieved during the internship, with
opportunity for discussion related to clinical skills/knowledge base and areas of recognized strength for
maximized growth and development.

The document is designed for the same tool to be utilized multiple times during the internship so that
progress across the continuum of the experience is easily discerned. Space is included for the evaluator
to make additional comments and define, when indicated, necessary and specific action plans for
successful achievement of competencies. The rating levels of 0, 1 and 6 as defined below are shaded in
grey as it is anticipated that they will be used sparingly and after careful consideration and
documentation of specific performance examples.

Disclaimer:
Use of this tool is voluntary. Application of and the results from the use of this tool are at the discretion
of the internship program. Results are not a guarantee of future performance.
 Intern Initials: _____
Internship Session: _____

RATING DEFINITIONS

0. Not Acceptable
The intern does not perform this skill at a level acceptable for a beginning child life intern, even when
provided considerable assistance by clinical supervisor. If little or no improvement is observed, intern
may be asked to withdraw from the internship.

1. Below Standard
The intern requires significant assistance in order to perform the skill or behavior. The intern is given
multiple opportunities to build skills and is having difficulty integrating feedback and improving skills. If
little or no improvement is observed, intern may be asked to withdraw from the internship.
 Assistance/Guidance: The intern performs this skill at a level comparable to that of beginning child
life intern when provided considerable assistance by clinical supervisor.
 % of Caseload: Clinical supervisor is unable to allow intern to function independently at this task
(0% of caseload).
 Amount of Follow-up Required: Follow-up is required with patients/families/staff by clinical
supervisor after nearly every time the intern performs this task.
 Initiative: Intern displays very little, if any, initiative towards performing this task.
 Ease of Performing Task: Intern’s apprehension around patients and families when performing this
task is consistent and apparent.

2. Standard Beginning Intern

The intern requires appropriate assistance in order to perform the skill or behavior, but is demonstrating
improvement in this area.
 Assistance/Guidance: The intern requires considerable assistance in order to perform the skill or
behavior, but is demonstrating improvement in this area.
 % of Caseload: Clinical supervisor is able to allow intern to function independently at this task <25%
of the time.
 Amount of Follow-up Required: Clinical supervisor is still observing and/or visually present. Clinical
supervisor finds it necessary to follow-up with patients/families/staff after intern performs this task
most—though not all—of the time.
 Initiative: Intern displays growing sense of initiative towards performing this task, however is often
prompted by clinical supervisor.
 Ease of Performing Task: Intern is beginning to display ease around patients and families.

3. Continued Improvement
The intern requires some assistance in order to perform the skill or behavior effectively most of the time.
 Assistance/Guidance: The intern requires occasional assistance in order to perform the skill or
behavior effectively.
 % of Caseload: Clinical supervisor is providing regular guidance regarding prioritization and skill set,
however, allows intern to function independently 25-50% of the time when performing this task.
 Amount of Follow-up Required: Intern takes direction and applies it appropriately. Some follow-up
is required with patients/families/staff by clinical supervisor when intern performs this task.
 Initiative: Intern takes the initiative to perform this task more often; clinical supervisor needs to
prompt approximately half of the time.
 Ease of Performing Task: Intern’s ease around patients and families is growing, and it is becoming
apparent when performing this task.

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 Intern Initials: _____
Internship Session: _____

4. Increasing Independence
The intern takes initiative and is able to begin tasks independently the majority of the time.
 Assistance/Guidance: The intern requires very little assistance in order to perform the skill or
behavior effectively.
 % of Caseload: Intern begins to share responsibility of patient load (example: “splitting the patient
load”). Intern functions independently 50-75% of the time. Clinical supervisor has to provide
guidance regarding prioritization only occasionally.
 Amount of Follow-up Required: Intern takes direction and applies it appropriately. Very little follow-
up is required with patients/families/staff by clinical supervisor when intern performs this task.
 Initiative: The intern takes initiative and is able to begin this task independently, most often without
prompting from the clinical supervisor.
 Ease of Performing Task: Intern’s ease around patients and families is consistent and apparent in
most interactions.

5. Job Entry
The intern is able to perform the skill or behavior effectively and independently. The intern applies the
skill in a manner expected of a child life intern ready to begin his/her first job as a child life specialist.
 Assistance/ Guidance: The intern is able to perform this skill or behavior effectively and
independently—not requiring the assistance of the clinical supervisor. The intern applies the skill in
a manner expected of a child life intern ready to begin an entry level position as a child life specialist.
 % of Caseload: Intern can assume most or all of the entire caseload of a child life specialist (75-
100%). Clinical supervisor very rarely provides guidance regarding prioritization.
 Amount of Follow-up Required: Intern consistently interacts appropriately with
patients/families/staff. Clinical supervisor does not find it necessary to follow-up with
patients/families/staff after intern’s interactions.
 Initiative: Intern takes initiative and always begins tasks independently.
 Ease of Performing Task: Intern’s ease around patients and families is consistent and apparent in
nearly all interactions.

6. Exceeds Job Entry

The intern performs the skill or behavior at the level of a child life specialist with 1-2 years experience.
 Assistance/Guidance: The intern performs this skill or behavior with an exceptional level of
expertise.
 % of Caseload: Intern can assume 100% of the child life specialist’s caseload and does not require
any guidance regarding prioritization of patient and family needs.
 Amount of Follow-up Required: Intern interacts with patients/families/staff exceptionally well. No
follow-up is required and patients/families/staff often comment on how well the intern performed at
this task.
 Initiative: Intern takes initiative to go above and beyond standard expectations, often thinking often
thinking of unique approaches to her/his work.
 Ease of Performing Task: Interns’ ease around patients and families is consistent and apparent in all
interactions and can even put others at ease by her/his presence.

N/A Not Applicable

The intern had no opportunity to demonstrate this skill or this skill does not apply in this patient area.

3
 Intern Initials: _____
Internship Session: _____

Domain I: Assessment

Standard Beginning
Task 1: Identify, obtain, and use relevant

Exceeds Job Entry

Below Standard
Not Acceptable

Not Applicable
data (e.g., health care, family, child)

Independence
Improvement
Intern

Increasing
Continued
regarding the child and family to develop

Job Entry
a comprehensive assessment and
initiate a plan of care
A. Effectively interprets and
incorporates pertinent data into 0 1 2 3 4 5 6 N/A
developing a child life plan of care
B. Uses developmentally appropriate
play as a primary tool in assessing
0 1 2 3 4 5 6 N/A
and meeting developmental and
psychosocial needs
C. Utilizes effective communication skills
to learn from children and families 0 1 2 3 4 5 6 N/A
and formulate patient- and family-
centered, culturally appropriate goals
D. Prioritizes child life services based on
comprehensive analysis of the needs 0 1 2 3 4 5 6 N/A
of patients and families
Areas of strength and proposed action plan(s):
- My abilities to assess play can be seen in my journals where I have provided descriptions of

patient behaviors including patients avoiding eye contact or hiding their face with an iPad when

my supervisor or I enter a bed space, fidgeting with a blanket or sucking on toys.

- I have had a few opportunities to lead introductions and conduct chart reviews following my

interactions with patient’s and families. During these interactions I am continuing to improve on

how I communicate including my language choice and my placement in the room. Journal 5

provides a description of my reflection on leading these introductions.

- I would like to continue to gain experience and skill conducting chart reviews and using that

information to guide interventions for patients and families in POH.

Standard Beginning

Exceeds Job Entry

Below Standard
Not Acceptable

Not Applicable

Task 2: Identify developmental factors and

Independence
Improvement
Intern

Increasing
Continued

their implications regarding the child’s

Job Entry

health care experience in order to plan

appropriate interventions

4
 Intern Initials: _____
Internship Session: _____

A. Accurately assesses patients'

developmental levels, identifying 0 1 2 3 4 5 6 N/A
strengths and vulnerabilities
B. Assesses the child's and family's concept
of illness, diagnosis, procedure, or 0 1 2 3 4 5 6 N/A
reason for visit
C. Utilizes knowledge of human growth
and development theory in identifying 0 1 2 3 4 5 6 N/A
relevant developmental considerations
for individual patients and families
Areas of strength and proposed action plan(s):
- My abilities to assess patient’s developmental level in POH is an area where I would like to
continue to grow. In journals I have demonstrated my abilities to make observations regarding
patient’s behaviors and connect them to theory but would like to improve on my abilities to
apply those observations into formal assessments of patient’s strengths and vulnerabilities
through chart notes.
- My understanding of the importance of collecting information regarding children’s concepts of
illness can be seen in my 4th therapeutic play activity. Here I utilized a method I have observed
my supervisor use to gather information about the child’s understanding of the visit by asking
the child to tell me “what’s going to happen today?”. This is an effective approach to gain
information about the child’s knowledge and perception of why they are at the hospital.
- I am looking forward to having opportunities to practice directly applying my knowledge of
developmental theory into how I provide support to children and families. Specifically, I wish to
improve my abilities to make observations and prioritize what information is most relevant in
guiding how I provide support.
Standard Beginning Intern

Task 3: Identify psychosocial factors

Increasing Independence
Continued Improvement

(e.g., diversity, culture, spirituality,

family dynamics and structure, coping
Exceeds Job Entry
Below Standard
Not Acceptable

Not Applicable

styles, socioeconomic status) and family-

identified needs and goals in order to
Job Entry

provide patient- and family-centered

care
A. Integrates assessment of psychosocial
and contextual factors in 0 1 2 3 4 5 6 N/A
understanding children's and families'
adjustment and behavior

5
 Intern Initials: _____
Internship Session: _____

B. Assesses key psychosocial and

contextual factors, identifying 0 1 2 3 4 5 6 N/A
strengths and vulnerabilities relevant
in developing a plan of care
C. Assesses the meaning for the child
and family of the illness, diagnosis, 0 1 2 3 4 5 6 N/A
procedure, or reason for visit
Areas of strength and proposed action plan(s):
- Examples of my abilities to assess patients and families can be seen in my journals. Here I discuss
observations related to family’s behaviors including who in the bed space speaks the most, if
anyone speaks for the patient and how the patient and family is positioned in the room. An
example of this is how I observed and recorded that Jadiel was sitting on his father’s lap while in
POH1.
- My journals also display my abilities to consider a variety of potentially influencing factors which
may impact a child and family’s behaviors and reactions to the medical setting. These factors
may include cultural factors, a patient’s past medical experience, mental health diagnoses such
as anxiety, perceptions of why they are at the hospital, their developmental level as well as if a
caregiver has custody of their child.
- An area where I wish to improve is integrating information gathered from chart notes into
assessments of the patient and family, and to engage in ongoing assessments through multiple
visits to the bed space.

Domain II: Intervention

Standard Beginning

Exceeds Job Entry

Below Standard
Not Acceptable

Not Applicable
Task 1: Provide psychosocially and
Independence
Improvement
Intern

Increasing
Continued

developmentally appropriate support

Job Entry

that is responsive to the specific needs

of children and families.
A. Identifies goals and interventions that
reflect accurate assessment of 0 1 2 3 4 5 6 N/A
individual needs and respect for
diverse cultural and family contexts
B. Adjusts goals and interventions as
needed to meet individual needs and 0 1 2 3 4 5 6 N/A
respect contextual factors
C. Coordinates child life programming
with multidisciplinary and family 0 1 2 3 4 5 6 N/A
goals as well as medical treatment
plans and care giving schedules

6
 Intern Initials: _____
Internship Session: _____

Areas of strength and proposed action plan(s):

- My continued improvement to meet patient and family’s individual needs can be seen in how I
provided support to Yoav and his family in POH1. Prior to entering the bed space Carrie and I
discussed information regarding how Yoav had been asked to leave the room during medical
discussions while on an inpatient unit and how to offer support while also respecting his parent’s
wishes to limit sharing medical information by carefully avoiding the use of terms such as
“surgery” or “procedure”.
- I am continuing to learn and gain experience utilizing the child life handoff tool and chart notes
to record and share information. One of the functions of the handoff tool is to communicate
additional child life programing and supports that the patient requested or would benefit from. I
am looking forward to continuing to gain experience and skill utilizing the child life handoff tool
to communicate and coordinate child life programming.

Standard Beginning

Exceeds Job Entry

Below Standard
Not Acceptable

Not Applicable
Independence
Improvement
Intern

Increasing
Continued
Task 2: Empower and collaborate with

Job Entry
children and families to develop and use
advocacy skills
A. Accurately assesses patients' and
families' strengths and preferences
0 1 2 3 4 5 6 N/A
for participating in care and decision-
making
B. Recognizes and facilitates
participation of patients and families
0 1 2 3 4 5 6 N/A
in ways that enhance their sense of
control and independence
C. Communicates with patients and
families in ways that demonstrate
respect for and affirmation of 0 1 2 3 4 5 6 N/A
individual experiences, preferences,
and perspectives
Areas of strength and proposed action plan(s):

- A way that I have enhanced patient’s sense of control while in POH is by providing realistic
choices such as selecting a diversional activity. Another way that I have helped to empower
patient’s is by asking if they have any questions or anything, they’re nervous about. Both of
these examples give patient’s opportunities to increase their sense of control while in POH.
- Examples of how I have communicated with patient’s and families in a way that respects their
individual experience is by affirming and normalizing feelings of anxiousness expressed by

7
 Intern Initials: _____
Internship Session: _____

patient’s and caregivers such as with Jadiel in POH1 and while walking caregivers out to the
nurse liaison office after their child had gone into the OR.

8
 Intern Initials: _____
Internship Session: _____

Standard Beginning
Task 3: Provide educational

Exceeds Job Entry

Below Standard
Not Acceptable

Not Applicable
opportunities and resources that are

Independence
Improvement
Intern

Increasing
Continued
responsive to the needs of children and

Job Entry
families in order to promote learning
and mastery
A. Assesses knowledge level,
misconceptions, previous
0 1 2 3 4 5 6 N/A
experiences, and unique socio-
cultural and learning needs
B. In collaboration with family members
and professionals, determines
realistic goals and objectives for 0 1 2 3 4 5 6 N/A
learning and identifies an action plan
to achieve these goals
C. Adjusts teaching to the conditions,
emotional states, developmental 0 1 2 3 4 5 6 N/A
abilities, and cultural considerations
of both the child and family
Areas of strength and proposed action plan(s):
- I have continued to learn about techniques for providing education and offering child life
services and supports by observing my supervisors in POH.
- Both Kate and Carrie modify approaches to promoting education based on ongoing assessments
and their knowledge of developmental theory. For example, if a child has a misconception about
anesthesia and is fearful that they might not wake up, the information and explanation provided
will be given using reassuring, positive and developmentally appropriate language.
- I wish to gain experience and independence providing education and support as the semester
progresses.

Task 4: Facilitate preparation (e.g.,

Standard Beginning

psychological, educational) for

Exceeds Job Entry
Below Standard
Not Acceptable

Not Applicable

challenging situations with children and

Independence
Improvement
Intern

Increasing
Continued

families in order to minimize fear and

Job Entry

anxiety and to promote mastery of their

experience
A. Engages in ongoing assessment of
potential stressors, recognizing and 0 1 2 3 4 5 6 N/A
responding to individual cues
communicated by child and family
B. Adjusts preparation approach to the 0 1 2 3 4 5 6 N/A
conditions, emotional states,
developmental abilities, and cultural
considerations of both the child and
9
 Intern Initials: _____
Internship Session: _____

family
C. Uses developmentally appropriate
and medically accurate teaching aids,
preparation techniques, and 0 1 2 3 4 5 6 N/A
terminology so that the child's and
family's knowledge is increased and
emotional needs are supported
D. Facilitates planning, rehearsal and
implementation of coping strategies 0 1 2 3 4 5 6 N/A
as part of preparation
Areas of strength and proposed action plan(s):
- My abilities to make ongoing assessments of children and families is evident in my conversations
with my supervisors following patient and family interactions and in my journals.
- My knowledge of preparation techniques can be seen in my 3 rd and 4th therapeutic play activities.
- I am looking forward to the opportunity to engage in providing education to children including
facilitating rehearsal and coping strategies.

Task 5: Facilitate the development of

Standard Beginning Intern

Increasing Independence
Continued Improvement

coping strategies for children and

families (e.g., pain management,

Exceeds Job Entry

Below Standard
Not Acceptable

Positioning for Comfort®, distraction,

Not Applicable
alternative focus, guided imagery, child
Job Entry

participation) in order to minimize

distress and promote empowerment
A. Accurately assesses children's and
families' distress and coping levels 0 1 2 3 4 5 6 N/A
and responses
B. Utilizes effective techniques to aid
child and/or parent coping during
procedures or stressful events with
0 1 2 3 4 5 6 N/A
appropriate consideration given to
developmental level and emotional
state
C. Utilizes appropriate psychological
0 1 2 3 4 5 6 N/A
pain management strategies
D. Supports parents to be present and
provide support to their child during 0 1 2 3 4 5 6 N/A
stressful events

10
 Intern Initials: _____
Internship Session: _____

E. Facilitates opportunities for play and

other developmentally appropriate 0 1 2 3 4 5 6 N/A
activities to decrease distress and
increase effective coping
F. Plans and implements activities to aid
immediate and long-term coping and 0 1 2 3 4 5 6 N/A
adjustment
Areas of strength and proposed action plan(s):
- My abilities to assess children and family’s coping and stress levels can be seen in observations
noted in my journals, including how a patient named Olivia appeared relaxed through her body
language and was very talkative and focused on engaging in a diversional activity with me while
in POH2.
- To provide diversional activities while supporting a playful environment I have selected
developmentally appropriate toys to have at the bed space of infant and toddler aged patients
prior or following their arrival to POH.
- I have offered patients of all ages diversional activities to engage in while in POH in order to
normalize the environment and promote coping skills through distraction. An example would be
providing a 21-year-old patient with a Mandala coloring book and pencils.
- I have promoted play in POH by sharing with caregivers that they do not need to stay in their bed
space but that they can take their child to ride in the cozy-coupe car around POH in a larger
circle.
Standard Beginning Intern

Increasing Independence
Continued Improvement

Task 6: Facilitate play (e.g., recreational,

health care, therapeutic) and familiar
Exceeds Job Entry
Below Standard
Not Acceptable

life experiences in order to encourage Not Applicable

expression, process information, and
Job Entry

promote development and

normalization
A. Identifies goals for play activities
based on individual assessment of
children's conditions and 0 1 2 3 4 5 6 N/A
developmental and psychosocial
needs
B. Facilitates opportunities for
therapeutic play that increase
0 1 2 3 4 5 6 N/A
children's mastery and coping with
health care experiences
C. Facilitates opportunities for play that
support individual developmental 0 1 2 3 4 5 6 N/A
needs and tasks
11
 Intern Initials: _____
Internship Session: _____

D. Creates adaptive environments and

activities for children whose access is 0 1 2 3 4 5 6 N/A
restricted by a specific diagnosis or
condition
Areas of strength and proposed action plan(s):
- My understanding of the importance of promoting therapeutic play activities in order to meet
developmental needs and increase a child’s mastery and coping while in POH can be seen in my
therapeutic rational sections of my therapeutic play activity assignments.
- I wish to continue to gain opportunities and increase my skills to facilitate opportunities for play
to increase children’s mastery and coping through medical play sessions.

12
 Intern Initials: _____
Internship Session: _____

Standard Beginning
Task 7: Evaluate and document

Exceeds Job Entry

Below Standard
Not Acceptable

Not Applicable
assessments, goals, interventions,

Independence
Improvement
Intern

Increasing
Continued
outcomes, and significant events in

Job Entry
order to communicate and modify care
plans as necessary
A. Evaluates effectiveness of
interventions based on outcomes 0 1 2 3 4 5 6 N/A
achieved and adjusts plan in response
B. Documents concisely, objectively, and
accurately in the child's medical
record, including developmental and 0 1 2 3 4 5 6 N/A
psychosocial issues pertinent to the
plan of care
Areas of strength and proposed action plan(s):
- I have continued to gain experience and improve my skills to write concise and accurate chart
notes. Through guidance and instruction from my supervisors I am continuing to learn what is
appropriate and most important to include in chart notes so that information that is shared is
relevant and written using professional language.
- I am looking forward in continuing to grow in my abilities to evaluate interventions and write
concise, objective chart notes as the semester progresses.

Domain III: Professional Responsibility

Standard Beginning

Exceeds Job Entry

Below Standard
Not Acceptable

Not Applicable
Task 1: Maintain professional standards
Independence
Improvement
Intern

Increasing
Continued

of practice through adherence to

Job Entry

established ethical guidelines in order to

provide respectful and competent care
A. Follows medical orders, infection
control, safety procedures, privacy 0 1 2 3 4 5 6 N/A
and confidentiality and all other
policies of the setting
B. Establishes and maintains
appropriate therapeutic relationships 0 1 2 3 4 5 6 N/A
and professional boundaries among
patients, families and staff
C. Identifies relevant ethical concerns
and participates in analysis of ethical 0 1 2 3 4 5 6 N/A
issues to guide practice

13
 Intern Initials: _____
Internship Session: _____

Areas of strength and proposed action plan(s):

- I have demonstrated my awareness and respect for patient and family confidentiality in all areas
of the hospital by informing a caregiver at the tailgate party that they are only allowed to take
pictures of their own child as a hospital policy. I have also informed a CLS that a volunteer had
been sharing inappropriate information regarding her experience seeing a patient’s family
outside the hospital. I then reflected upon the importance of maintaining HIPPA in my journal.
- I am aware of following precautions signs at the entrance of patient’s bed spaces while in POH.

Standard Beginning Intern

Task 2: Promote professional

Increasing Independence
Continued Improvement
relationships (e.g., child life team,
interdisciplinary teams, community

Exceeds Job Entry

Below Standard
Not Acceptable

Not Applicable
resources) in order to enhance
communication and collaboration, foster

Job Entry
patient- and family-centered care, and
maximize positive outcomes
A. Collaborates with family members
and professionals to integrate
0 1 2 3 4 5 6 N/A
interdisciplinary and family goals into
child life services
B. Communicates effectively with team
members through case conferences,
rounds, and other informal and 0 1 2 3 4 5 6 N/A
formal contacts pertinent to the
needs of the child and family
C. Recommends referrals when the
needs of the child and family are 0 1 2 3 4 5 6 N/A
beyond the scope of child life practice
Areas of strength and proposed action plan(s):
- My abilities to promote the development of professional relationships with CLS and
interdisciplinary team members can be seen in my daily interactions with CLS, nursing, CA’s, the
behavioral analyst and anesthesia. Examples of this include brief interactions such as asking if a
bed space is being used or more formal forms of communication through emails sent to BCH’s
SIM program in order to arrange an interview with their Simulation Production Engineer.
- I am looking forward to continuing to gain skills and experience communicating with members of
the multidisciplinary team such as making referrals through email, phone calls and direct
interactions.

14
 Intern Initials: _____
Internship Session: _____

Standard Beginning
Task 3: Educate staff, students,

Exceeds Job Entry

Below Standard
Not Acceptable

Not Applicable
volunteers, and the community in order

Independence
Improvement
Intern

Increasing
Continued
to promote greater awareness of the

Job Entry
needs of children and families as well as
the child life profession
A. Provides comprehensive volunteer
orientation in their assigned area and 0 1 2 3 4 5 6 N/A
to the child life program
B. Delegates volunteer duties and
assignments effectively, matching
volunteer ability to complexity of task 0 1 2 3 4 5 6 N/A
and communicating expectations and
roles clearly
C. Participates in giving and receiving
volunteer feedback in a constructive 0 1 2 3 4 5 6 N/A
manner
D. Demonstrates effective advocacy for
psychosocial issues and the child life 0 1 2 3 4 5 6 N/A
profession
E. Applies child life knowledge and
evidence-based practice to contribute
to the education and awareness of 0 1 2 3 4 5 6 N/A
others within the setting and
community
F. Communicates information
effectively, integrating basic concepts
of public speaking and teaching 0 1 2 3 4 5 6 N/A
methods appropriate to subject
matter and audience
Areas of strength and proposed action plan(s):

- This semester I have assisted in orienting a volunteer to POH by showing and explaining the
importance of the toy cleaning protocol. I also showed this volunteer where the red storage
room was and how to blow up balloons to decorate POH.
- I have been instructed to give directions in the future to volunteers if there is a need or task that
would be helpful for them to complete, such as cleaning toys.

15
 Intern Initials: _____
Internship Session: _____

Task 4: Recognize and document

Standard Beginning
administrative responsibilities (e.g.,

Exceeds Job Entry

Below Standard
Not Acceptable

Not Applicable
quality improvement, staffing, and

Independence
Improvement
Intern

Increasing
Continued
resource allocation, policies, and

Job Entry
program evaluation) in order to ensure
quality services
A. Organizes and manages time
effectively, balancing direct and
0 1 2 3 4 5 6 N/A
indirect care responsibilities
appropriately
B. Maintains supplies and equipment
with attention to budgetary 0 1 2 3 4 5 6 N/A
constraints
C. Collects, analyzes and reports
accurate and pertinent data in a 0 1 2 3 4 5 6 N/A
timely manner
D. Provides feedback relevant to
continuing program improvement, 0 1 2 3 4 5 6 N/A
identifying opportunities and needs
to promote positive change
Areas of strength and proposed action plan(s):
- This semester I have demonstrated time management skills by being punctual arriving to BCH
and when returning from breaks as well as managing my time efficiently while performing tasks
and assignments.
Standard Beginning

Task 5: Engage in continuing education

Exceeds Job Entry
Below Standard
Not Acceptable

(e.g., educational opportunities, relevant Not Applicable

Independence
Improvement
Intern

Increasing
Continued

medical information, technology,

Job Entry

research & literature) in order to

promote professional development
A. Participates actively in educational
offerings throughout the internship,
demonstrating critical thinking skills 0 1 2 3 4 5 6 N/A
and insight into application in
practice
B. Uses current developmental theory
and research to guide assessment of
0 1 2 3 4 5 6 N/A
and identify rationale for child life
plan of care
C. Identifies personal learning needs
and develops effective learning plans, 0 1 2 3 4 5 6 N/A
accessing available resources

16
 Intern Initials: _____
Internship Session: _____

Areas of strength and proposed action plan(s):

- This semester I have engaged in several forms of continued education. I have conducted an
interview with the Simulation Production Engineer of BCH’s SIM program, I have attended
weekly child life in-services, and I have participated in a SIM discovery event and learned about
how the SIM program collaborates with child life.
- I have also conducted article reviews, attended a brief talk introducing child life to new nursing
staff, attended a PERCS rounds meeting, and I have or am in the process of arranging dates to
shadow CLSs in the PawPrints program and the NICU. Lastly, I attended a full-day NECLP
conference in Connecticut.

17
 Intern Initials: _____
Internship Session: _____

PROFESSIONAL SKILLS

KEY: 1=Unacceptable performance

2=Meets expectations
3=Outstanding performance

1 2 3
Reflective Practice
Recognizes and demonstrates willingness to explore how personal challenges, M
learning needs, cultural and personal beliefs impact professional practice.
Engages in self-reflective practice, demonstrating realistic and critical thinking M
regarding own performance, and incorporates insights into practice.
Engagement in Supervision
Readily accepts and integrates supervision and feedback from supervisor and other M
members of health care team.
Seeks support from mentors, peers, and supervisors. M
Contacts both clinical and academic supervisors in a timely manner when absences M
are necessary or other concerns arise so they may be addressed.
Initiative
Is motivated to learn. M
Follows through on specific assignments and tasks. M
Accepts responsibility and demonstrates initiative in work. M
Professional Presentation of Self
Maintains a positive attitude, is tactful, and considerate. M
Demonstrates adaptability and flexibility in the health care environment. M
Remains calm in stressful situations. M
Demonstrates respect for others’ points of view. M
Practices careful attention to verbal and written communication and to personal M
appearance.
Maintains confidentiality of children, families, and staff in and out of the health care M
setting.
Time Management
Completes site assignments on time. M
Attends meetings and other scheduled responsibilities on time. M
Adheres to work hours and schedule. M

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 Intern Initials: _____
Internship Session: _____

EVALUATION OF CORE ASSIGNMENTS

Note: Additional lines are included for other core assignments to be added as appropriate to individual internship programs.

KEY: 1=Unacceptable performance

2=Meets expectations
3=Outstanding performance
1 2 3
Journal M
Therapeutic Activities M
Interviews M
Article Reviews M

Midterm Evaluation Reviewed & Discussed with Supervisor:

Rotation: ____________________________________ Date: _________________________

Supervisor Signature: __________________________ Intern Signature: _____________________________

Wheelock/BU Academic Supervisor Signature:_________________________________________

Additional Comments:

Final Evaluation Reviewed & Discussed with Supervisor:

Rotation: ____________________________________ Date: _________________________

Supervisor Signature: __________________________ Intern Signature: _____________________________

Wheelock/BU Academic Supervisor Signature:_________________________________________

Additional Comments:

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