"Graduate Student Extern Evaluation Form"

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GRADUATE STUDENT EXTERN EVALUATION FORM
Student:__________________________ Date of evaluation:____________________
Site:_____________________________ Supervisor:__________________________
□ First full-time internship
□ Second full-time internship
Check one:
Check one:
□ Midterm evaluation
□ Final evaluation
Caseload includes (check all that apply):
Age groups:
□ Early childhood (birth-grade 2)
□ Childhood (grades 1-6)
□Middle Childhood (grades 5-9)
□ Adolescence
□ Adult
Disorder types/Areas Addressed:
□ Phonology/Articulation
□Fluency
□Voice
□ Language
□ Cognitive aspects of Communication
□AAC/AT
□ Social communication
□ Aural Rehab
□Hearing screenings
□ Feeding/swallowing
□ High-risk population (specify) ______________________________________
*****
□ Culturally/linguistically diverse population: specify in detail the
backgrounds of those students with whom the intern worked:
_______________________________________________________________________
0
1
2
3
Knowledge and Skills (CCC Standards)
Skill Not
Emerging
Adequate
Strong
Apparent
Demonstrates understanding of the organizational structure and chain of
command (ASHA CCC Standard IV-G-3)
Interprets assessment data accurately (IC-G-1-e)
Generates functional treatment goals appropriate to needs of client (IV-G-2-a)
Chooses procedures and materials appropriate to treatment objectives (IV-G-2-
c)
Implements therapy in an efficient and accurate manner (IV-G-2-b)
Documents client performance in an efficient and accurate manner; daily SOAP
notes if appropriate (IV-B; IV-G-2-f)
Demonstrates understanding of social aspects of communication (III-D)
Utilizes suggestions from families and patient in treatment programming (IV-G-
2-g)
Accurately and appropriately explains information and procedures to patient
and families or caregivers (IV-G-3-a; IV-G-3-c)
Presents information in a conference format in a clear and understandable
manner (IV-G-3-a; IV-G-3-d)
Demonstrates professional behaviors including timeliness and dress appropriate
to environment (III-E; III-G; IV-G-3-d)
Contributes information and resources to the team (IV-G-3-b)
Is able to problem solve as needed or find the resources to effectively cope with
the problem (IV-G-3)
Deals with conflict in a professional manner (IV-G-3)
Adheres to Code of Ethics and other practice guidelines (IV-G-3)
GRADUATE STUDENT EXTERN EVALUATION FORM
Student:__________________________ Date of evaluation:____________________
Site:_____________________________ Supervisor:__________________________
□ First full-time internship
□ Second full-time internship
Check one:
Check one:
□ Midterm evaluation
□ Final evaluation
Caseload includes (check all that apply):
Age groups:
□ Early childhood (birth-grade 2)
□ Childhood (grades 1-6)
□Middle Childhood (grades 5-9)
□ Adolescence
□ Adult
Disorder types/Areas Addressed:
□ Phonology/Articulation
□Fluency
□Voice
□ Language
□ Cognitive aspects of Communication
□AAC/AT
□ Social communication
□ Aural Rehab
□Hearing screenings
□ Feeding/swallowing
□ High-risk population (specify) ______________________________________
*****
□ Culturally/linguistically diverse population: specify in detail the
backgrounds of those students with whom the intern worked:
_______________________________________________________________________
0
1
2
3
Knowledge and Skills (CCC Standards)
Skill Not
Emerging
Adequate
Strong
Apparent
Demonstrates understanding of the organizational structure and chain of
command (ASHA CCC Standard IV-G-3)
Interprets assessment data accurately (IC-G-1-e)
Generates functional treatment goals appropriate to needs of client (IV-G-2-a)
Chooses procedures and materials appropriate to treatment objectives (IV-G-2-
c)
Implements therapy in an efficient and accurate manner (IV-G-2-b)
Documents client performance in an efficient and accurate manner; daily SOAP
notes if appropriate (IV-B; IV-G-2-f)
Demonstrates understanding of social aspects of communication (III-D)
Utilizes suggestions from families and patient in treatment programming (IV-G-
2-g)
Accurately and appropriately explains information and procedures to patient
and families or caregivers (IV-G-3-a; IV-G-3-c)
Presents information in a conference format in a clear and understandable
manner (IV-G-3-a; IV-G-3-d)
Demonstrates professional behaviors including timeliness and dress appropriate
to environment (III-E; III-G; IV-G-3-d)
Contributes information and resources to the team (IV-G-3-b)
Is able to problem solve as needed or find the resources to effectively cope with
the problem (IV-G-3)
Deals with conflict in a professional manner (IV-G-3)
Adheres to Code of Ethics and other practice guidelines (IV-G-3)
SUMMARY
Please add comments on the reverse or on a separate page as needed.
1. Student’s Growth:
□ Substantial
□ Moderate
□ Minimal
Comments:
2. Level of independence relative to student status:
□ Exceptional
□ Adequate
□ In need of continued supervision
Comments:
3. Ability to handle documentation demands:
□ Accurate and efficient
□ Adequate (feedback helpful) □ Guidance needed
Comments:
4. The student showed a strong theoretical foundation for the placement:
□ Yes □ No
5. The student was able to apply treatment procedures appropriately:
□ Yes □ No
6. The student demonstrated critical thinking and problem-solving skills:
□ Yes □ No
7. The student maintained professional and ethical behaviors:
□ Yes □ No
Please comment on any “No” responses:
Additional comments (use reverse or attach as needed):
Recommended grade:__________
_____________________________________
________________________________
Supervisor
Student
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