(CUYAHOGA COMMUNITY COLLEGE HUMAN SERVICES PROGRAM. ance nanien tf sruvents Fi) (ore) semester iblver ti is #_ZDINSTRUCTOR: rmacrewnsre (stl ADDRESS: crty/zie cont PHONE NUMBER: ‘SUPERVISOR NAME: NUMBER OF TERMS THE STUDENT HAS BEEN IN, AT YOUR PRACTICUM SITE: Z PRACTICUM DATES: FROM_ “4-271. /] roy 7 JIG STUDENT SPECIALIZATION: __“GENERALIST ___CHEMICAL DEP. DESCRIBE THE TYPE OF AGENCY: health center, ete.) ‘group home, treatment center, mental Private non-profit, \Public non-profit, _For profit ed to-a specific program within the Agency, please identify the ‘name and address.CLIENT CHARACTERISTICS Indicate the age, gender and socio-cultural background ofthe clients served by the student: AGE: __Presschool_=Pre-teen Adolescent _ Adult __ Seniors GENDER: Male __-Female PROBLEM AREAS OF THE CLIENT POPULATION SERVED BY THE STUDENT: (check all that apply) Aire ____ Income Maintenance acing Leaming Problems ‘ibs ZZ Legal Systems piston = inl Rteettrose ‘Anti-social Behavior ental Health temical Dependency aren Child Problems Zcnita Protection = Physical Disability Grisis Intervention Poverty “7 domesic Violence ~ Otter pect) © Developmental Challenges — Employment Family Problems Homelessness SOCIO-CULTURAL BACKGROUND Please identify the racial, ethnic and socio-economic background of the clients served by Tima Tin Es apeQUALITY OF PROFESSIONAL DEVELOPMENT. EVALUATION CRITERIA: Using te following criteria, please rate the student on Professional Development, Using the same form, students wil be evaluated at mid- semester and the end ofeach semester. During the mid semester evaluation, students ‘may score a | or 0 in anarea. By the end of the semester, students must perform at a rating of2 or better to successfully complete the course. Performance meets or exceeds the agency standards Performance is satisfactory/average Performance needs improvement Performance is unsatisfactory (CCC Instructor has been notified) ‘A.) Organization and Planning: Onis: nd manages tine Solomonertaconeceped fl a- B.) Decision Making: Resgsizs polenta stems oe ee Sects paper eone a 2 ) Dependability: tt sen re meee ase oc aan pet gn Se Ee ee am Ao = 1) aitative: Acs poy win tik depen ae: Coniseny snes ga ewes eomsesicyemooaes A _ = E,) Resourcefulness: Readily determines an ahtemative course of plan’ Roorcteaes, ta cement SS g- _Q- F Adapeabilly: Fett emts apie ne wore a G.) Enthusiasm: Minin oie catok demons ‘won dns ws a 2 1) Taterpersonal Sklls Glass ne bh, sso Sctowmdeatimewvocastansate a= 1 Professional Values and Ethical Conduct Ades to pls and pedis oft sn ad pres prog conti Seitwen hoes gry an farsa sep ana rege apeisin| ed {hd pane: pet and malas he concn of het an personel 1) Verbal and Nonverbal Communication: Lise an flows recor agen ee prises in dest nd mane ‘erons ote tones wool peop pesindciens ATRK.) Written Communication: winen wrt swell rie ht, ces mentions ad- L) Professional Development: Ksows nd wes sion! emrcesand ‘cece apropitly:nsve of pera presale and ‘wena mega: clsoa ling at practicum serio a Keser tamed sonnet 9 I_QUALITY OF PRACTICE/COMPETENCY SKILLS ‘Students are expected to develop sills in each ofthe competency areas, throughout their 3 semesters of practicum. Please complete the following: 1.) Identify the competency skills the student has on thi semester, by checking the space next to the skills. 2) Provide a rating of performance (using the scale identified above) for exch ‘competency skill, at mid-semester and the end of semester. 3) Document comments on student performance for each competency shill, ‘addressing the extent that each goal was met, were there modifications required, student's strengths and areas of weakness. sheet for this ‘Students may also continue to demonstrate additionel competencies not identified on ‘heir goal sheet, in the performance oftheir duties at the agency. Please evaluate students ‘on these competencies as well, by providing comments In the space provided. (Check here if chosen as # RATING: fa semester competency ‘MIDSEMESTER END SEMESTER 1) INTAKE: COMMENTS:_ ‘2)ASSESSMENT: _ COMMENTS:__ 3) SCREENING: _ COMMENTS:pe a4 pe fe Hp ‘COMMENTS: 6. CASE MANAGEMENT, < no a Chae gsi tel Dh fate sel? Let pa Cts peabn | Ase CPuA tls aH? ih ‘OMMENTS: utees .CORD KEEPING:, AhVtio Udtet a wih phecerenied! oe pine COMMENTS: 10. CO-THERAPY. ‘COMMENTS: — ——11. GROUP FACILITATION (CO-FACILITATION) COMMENTS; oo 12. FACILITATION OF FAMILIE! COMMENTS: 13. apvocacy: |“ ae a ia tt AZ Le Lal Spin eae HE Seattle eae ah Me ead eg Bh disap, Ted ie adh dde § iis ts PREVENTION —_ —— ore. COMMENTS: 18, BEHAVIOR CHANGER: COMMENTS:, For the areas of practice that have a numeric rating, compute a mean score,( add scores together and divide by the number of scores for mean rating) RATING= a fe a Date Evaluation ‘DateEND OF THE SEMESTER SUMMARY STATEMENT. STUDENT'S PROFESSIONAL 5) fi yu He GLa ADDITIONAL AREAS NEEDED FOR STUDENT DEVELOPMENT: VI IF STUDENT IS GRADUATING, PLEASE COMMENT ON STUDENT'S PREPAREDNESS FOR EMPLOYMENT AND SPECIFIC AREAS OF HAVE READ AND PARTICIPATED IN THIS EVALUATION: ‘SIGNATURE OF SUPERVISORIDAT! Suey Huackal CTORDATE Rev. ID 2001