FIELD INSTRUCTION II

EVALUATION FORM of SELF and for AGENCY FIELD SUPERVISOR

Working with Communities

Name of Intern: Date:

Faculty Field Instructor: Agency Field Supervisor:
PRC License Number: PRC License Number: __________________________
Agency: Period of Internship:

Instruction:
Check the box of the appropriate rating that describes your internship experiences, demonstrated
competencies and overall internship learnings. Below are the descriptions of the ratings:

Rating Verbal Indicators

Description
4 Excellent
3 Satisfactory
2 Fair
1 Poor
NA Not Applicable
Exceeds expectation in performance. Learning goals
achieved. Intern’s work is an added value to the agency and
co-interns. Submitted requirements completely, with few
revisions and ahead of time. Exhibits proficiency on skills in
areas of competency identified. Has initiative and is self-
motivated.
Achieved expectations. Learning goals achieved. Completed
requirements with revisions and on time. Exhibits beginning
skills in areas of competence identified. Has initiative.
Did not completely meet expectations. Submitted
incomplete requirement and not on time. Has difficulty
demonstrating skills expected. Has less initiative but is open
to learning and improving self.
Performance are below standards. Incomplete
requirements and always late. Minimal skills demonstrated
or not at all. No enthusiasm and initiative.
The expected performance cannot be achieved yet in the
specified evaluation period

1. Knowledge Excellent Satisfactory Fair Poor NA

4 3 2 1
1.1 INTERN can explain the
course objectives and policies of
Field Instruction.
1.2 INTERN can describe the
agency’s vision, mission, goals,
programs, services and
clientele.
1. Knowledge Excellent Satisfactory Fair Poor NA
4 3 2 1
1.3 INTERN can interpret the
agency’s programs, services and
policies to clients, co-workers,
other stakeholders and the
general public.
1.4 INTERN can identify the legal
duties that apply to all helping
professionals.
1.5 INTERN can enumerate the
fundamental values and
principles of social work applied
in the professional helping
relationship with assigned
individual clients and groups.
1.6 INTERN can explain the
helping functions, tools, skills
and techniques used in the
helping process with assigned
community.
1.7 INTERN can explain and
examine the socio-cultural,
economic, political and religious
realities of assigned community.
1.8 INTERN can articulate the
presenting, working and
underlying problems
experienced by the assigned
community.
1.9 INTERN can identify
appropriate programs, services
and interventions needed to
address the problems of the
assigned community.
1.10 INTERN has the knowledge
in making an action/intervention
plan for the community,
including utilization of resources
inside and outside of the
agency.
2. Skills Excellent Satisfactory Fair Poor NA
4 3 2 1
2.1 INTERN has applied the
theories and knowledge learned
from school with the existing
realities of assigned community.
2.2 INTERN can demonstrate
good interviewing skills among
individuals, families and groups
in the community.
2.3 INTERN has shown the
ability to effectively gather data
and information from
community members and
pertinent sources for problem
solving.
2.4 INTERN can sufficiently
formulate an assessment
statement, using social work
theories, of the community’s
problematic situation and
realities
2.5 INTERN has effectively
involved concern individuals and
groups in the community for
planning sessions and
identification of resources.
2.6 INTERN has established
linkages and networks for
mobilization of resources inside
and outside of the agency to
help client community.
2.7 INTERN has effectively use
verbal and nonverbal
communications and body
languages skills
2.8 INTERN has effectively use
the active-listening skills.
2.9 INTERN has formulated a
quality agency profile with
intern’s reflection.
2.10 INTERN has written a
quality reflection report on the
Agency Field Supervisor’s work,
values and qualities as a social
worker.
2. Skills Excellent Satisfactory Fair Poor NA
4 3 2 1
2.11 INTERN has formulated a
quality semestral plan of his/her
work assignment for the
semester in the agency and
community.
2.12 INTERN has formulated a
comprehensive questionnaire
for the community profile.
2.13 INTERN has produced an
updated and representative
community profile of the
assigned community.
2.14 INTERN has written a
quality community case study
report of the assigned
community.
2.15 INTERN has formulated
quality training design for use in
assigned community.
2.16 INTERN has submitted a
relevant and quality project
proposal for community
improvement.
2.18 INTERN has written one (1)
quality minutes of meeting from
attendance in community
meetings.
2.19 INTERN has formulated one
(1) quality community meeting
process recording of the
assigned community.
2.20 INTERN has regularly
formulated and submitted to
the agency field supervisor
his/her monthly work plan.
2.21 INTERN has regularly
formulated and submitted to
the agency field supervisor
his/her monthly
accomplishment report.
2.22 INTERN has regularly
written and submitted to agency
and school supervisors his/her
journal as basis for individual
and group conferences.
2.23 INTERN shows diligence in
work duties that he/she is not
lagging behind the required
Field Instruction hours.
2.24 INTERN is skillful in
recording and documentation
(e.g. community profile, process
recordings, minutes of meeting,
referral letters, etc.) and
maintain them as helping tools
in community organizing.
2.25 INTERN can effectively
conduct evaluation sessions
and/or closure session with
groups and community
members.
3. Attitude Excellent Satisfactory Fair Poor NA
4 3 2 1
3.1 INTERN is open to
constructive feedback and
effectively utilize feedback for
improvement
3.2 INTERN can easily establish
good working relationships with
supervisor, agency staff, co-
interns and community people.
3.3 INTERN utilizes supervisory
sessions productively.
3.4 INTERN submits reportorial
requirements completely, with
quality and on time.
3.5 INTERN observes and
comply with office policies and
rules.
3.6 INTERN identifies with the
Vision, Mission and Goals of the
agency and translate these into
action in his or her work.
3.7 INTERN displays punctuality
and regularity in reporting to
work and coming on time in
commitments with co-workers
and clients.
3.8 Attendance at conferences,
agency meetings, and related
activities.
 3. Attitude Excellent Satisfactory Fair Poor NA
4 3 2 1
3.9 INTERN shows his/her
initiative and resourcefulness to
achieve assigned tasks.
3.10 INTERN shows willingness
to learn and accept work
responsibilities.

Compute the mean for each category. Add all the means and divide the sum by 3. Refer to the grading
guide below:
Grading Guide:

Lower Limit Upper Limit Verbal Description

3.26 4.00 Excellent
2.51 3.25 Satisfactory
1.76 2.50 Fair
1.00 1.75 Poor

OVERALL GRADE:

Comments:

Prepared by:

________________________
Printed Name over Signature
For Supervisor: PRC ID # __________________
Expiration date _____________