Practicum Evaluation
Please print this form by sending to your local printer.
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Semester(CircleOne):
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Fall
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Spring
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Summer
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Year:
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Student's Name
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Address
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Phone
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SS#
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Major
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Placement Agency
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Supervisor
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Agency Address
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Agency Phone
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Date
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Field Supervisor Report: To be completed by supervisor listed above
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Hours completed by student (per week)
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Total hours during the semester
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Practicum activities and duties
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Please describe the nature of the student's activities and responsibilities with your agency
(Use additional page if necessary) |
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Please comment on the extent to which you feel the student has fulfilled his/her commitment to
your agency (Use additional page if necessary) |
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Recommend Grade: (Circle one)
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A
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A-
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B+
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B
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B-
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C+
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C
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C-
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D+
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D
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D-
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F
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Overall rating of placement
(Circle one) |
Excellent -------- Good ----------- Fair ---------- Poor
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Comments
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Signature of Field Supervisor
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Date
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If you need further information regarding Practicum opportunities contact:
Dr. Michael Caserta, Practicum Coordinator
801-793-5705
michael.caserta@nurs.utah.edu
