Undergraduate Classwork & Field Evaluation Form

Advanced Standing Program Applicants only
Undergraduate Classwork & Field Evaluation Form
Information requested on the attached form, to be filled out by a faculty member, assists us in evaluating the student’s capacity to
function at a third-semester graduate performance level. The report should include both semesters of the senior year but should be
submitted by mid-second semester. Should the information not be available for a complete assessment, we would appreciate an
interim report.
To be completed by the applicant
Applicant’s name ______________________________________
Social Security Number _____________________________
Program Advisor _________________________________ College/University _____________________ Date_____________
Under the Family Educational Rights and Privacy Act of 1974 (Buckley Amendment), which gives students the right to inspect and
review their educational records, students may waive their right to see confidential statements and letters of evaluation. The applicant
will have access to this information if admitted to and enrolled in the program, unless he/she waives the right to see it.
I waive my right to examine this letter.
signature ____________________________________
I do not waive my right to examine this letter.
signature _________________________________________
To be completed by the advisor (Please use separate sheets of paper if necessary.)
FIELD WORK AGENCY
(Junior Year)
Name of Agency ____________________________________________________________________________
Type of Agency ____________________________________________________________________________
Length of Assignment ________________________________________________________________________
Please describe the assignment in as much detail as possible (modality, length of contact, focus of service, etc.)
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
(Senior Year)
Name of Agency ____________________________________________________________________________
Type of Agency ____________________________________________________________________________
Length of Assignment ________________________________________________________________________
Please describe the assignment in as much detail as possible (modality, length of contact, focus of service, etc.)
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
(continued on reverse side)
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FIELD WORK PERFORMANCE
Please describe the level of practice developed by the student in work with individuals, families, groups and/or communities.
Identify specific skills required for further development, and specific lack of skills reflected in pronounced learning gaps. Brief
illustrations from junior and/or senior year assignments would be appreciated.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
JOB MANAGEMENT
Please describe the student’s capacity to handle workload (recording, reports, use of time, etc.)
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
FIELD INSTRUCTION
Supervision Junior Year Senior Year
Was the student supervised by an MSW yes no yes no
Was the student supervised individually yes no yes no
How often was the student supervised weekly bi-monthly weekly bi-monthly
Other (explain) _________________________________________________________________________________
Process Recordings
Required yes no yes no
If no, describe __________________________________________________________________________________
AGENCY EVALUATION
Was there a written evaluation at the end of each
semester or at the end of the academic year semester year
Did the student read and agree with the final evaluation yes no
ACADEMIC PERFORMANCE
Please comment on the applicant’s academic performance, intellectual capacity, ability to think logically and clearly and ability to
integrate theory and practice.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
SUMMARY:
Taking all of the above into consideration, do you think the applicant is capable of functioning at the beginning third semester
graduate level
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Signature _____________________________________________________
Date _________________________________
Please return to applicant in a sealed envelope with your signature across the back flap.
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