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    CUYAHOGA COMMUNITY COLLEGE HUMAN SERVICES PROGRAM. PRACTICUM EVALUATION ovum Ces __snesren Spee 19 COURSE: HS # sssppomucron Qa ——__ PRACTICUM SITE:, ADDRESS: crryizir covE:, PHONE NUMBER: - d SUPERVISOR NAME: NUMBER OF TERMS THE STUDENT HAS BEEN IN, AT YOUR PRACTICUM Simm | sono oD PRACTICUMDATES: FROM, Qo St) 1 STUDENT SPECIALIZATION: _—“GENERALIST _——CHEMICAL DEP. DESCRIBE THE TYPE OF AGENCY: (eg. group home, treatment center, mental health center, ete.) atta FUNDING SOURCE: __Private non-profit, Public non-profit, __For profit I the student is assigned to a specific program wit ‘name and address, the Agency, please identify the ‘CLIENT CHARACTERISTICS. ‘Indicate the age, ender and socio-cultural background of the clients served by the ‘student: LAGE: __Pre-school__~Pre-teen_/Adolescent__ Adult _ Seniors GENDER: “Male _-“Femate PROBLEM AREAS OF THE CLIENT POPULATION SERVED BY THE STUDENT: (check all that apply) LZ Abuse __ Income Maintenance Aging ‘Leaming Problems Alps LZ. tonal Systems Alcohotim Marital Protlems/dvoree —Z Anti-social Behavior Mental Health > Chemical pendency Paren/Child Problems Child Protection. il (Crisis Intervention ‘Domestic Violence Developmental Challenges Employment “Z_ Family Problems Homelessness SOCIO-CULTURAL BACKGROUND Pease dete rc, ni an pci gsonomicbaclyrou of thy let served the student “Hhiiaaly LE datevi0an Waa Pals LD) )PMENT EVALUATION CRITERIA: Using the following criteria, please rate the student on Professional Development. Using the same fort, students will be evaluated at mid- semeste: and the end of each semester. During the mid ~semester evaluation, students ‘may score a | orO in an area. By the end of the semester, students must perform at a rating of 2 or better to successfully complete the course. Ferformance mocts or exceeds the agency standa 3 Performance is satisfactory/average =2 Performance needs improvement = Performance is unsatisfactory (CCC Instructor has been notified) 0 A.) Organization and Planning: orgaie ant masge tine lst competes sk win pst ine fe povies ‘Seat iflrmtinn ss work and eves completo a B.) Decision Making: Resi probenspcti poten ‘nakes sound dessions under pressure, exereises good jaca, l A- ‘Sonne progr owerd opencance —_l_ C.) Dependability: Fetions rough with anne ngs orl tbe avi ering with profesional gatos, - Fomps mec profesional ema /oton oe! wi ce, 2 1D.) Initiaive: Ao romp ing ae inpnd ston: Coes tae pa volo euacly sa te ~ a 1B) Revourcefalnes: Randy csi en skies ea sion noite cmp salon! hang pens ore Sochiniign tlscwiorten men 2 A .) Adaptability: be denon postve aid aw ‘sige, ange sal evesy a _4 G_) Bndhusinsm: Minos stint; drone ‘enn ipl eratendety zz a 1H) Interpersonal Skills: Condes ifn ctl poesia ‘pnt mms, nc elite cooperate and ep ‘ele aod aie nbato wake oan er er A 11) Professional Values and Ethieal Conduct: Aitewsto piles nd proses of he ett and practicum progam: ona GREG ps tine rere eet SEES SET 8 41) Verbal and Nonverbal Communication: Liste snows clos reac icin nd xing, SESE ait ahdemtea tend prep poe tnt oR x K,) Written Communication: Writes work wet guia, dae, ‘once, poecial snconisewihthe dosmsnaenpelis ood 2 ‘pce of heogoey = LL) Professional Development: Koow and wes econ rene nd gon eis evan ef ee fel gd Sa ae sn ronment eo \LITY OF PI ETE! ‘Students are expected to develop skills in each ofthe competency areas, throughout their 3 semesters of practicum. Please complete the following: 1) Identify the competency skills the student has on their goal sheet for this semester, by checking the space next to the skill. 2,) Provide a rating of performance (using the seale identified above) for each ‘competency skill, at mid-semester and the end of semester. 3.) Document comments on student performance for each competency skill, addressing the extent that each goal was met, were there modifications ‘required, student's strengths and areas of weakness. ‘Students may also continue to demonstrate additional competencies not identified on their goal sheet, inthe performance oftheir duties atthe agency. Please evaluate students ‘on these competencies as wel, by providing comments in the space provided. (Check here if chosen as #RATING: ‘semester competency MIDSEMESTER END SEMESTER 1) INTAKE: COMMENTS: 3) SCREENING: _

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