Agency evaluation of student

Community Health Education

University of Minnesota Duluth

Student:           _______________      Agency:  ___________________

Supervisor:      _______________      Date:        ____________________

This is the ___ midterm   ___ final  evaluation (check one).

This evaluation was filled out by:        __________________________

Please use the following Likert scale:

4=Exceptional             

3=Above average

2=Average

1=Needs attention

0=No opportunity to observe

SC= See comment (this offers an opportunity for you to comment at the end)

Work performance

1.  Ability to work with co-workers.

4          3          2          1          0          SC

2.  Ability to work with other professionals in the field beyond the agency.

4          3          2          1          0          SC

3.  Ability to work with the public.

4          3          2          1          0          SC

4.  Leadership qualities.

            4          3          2          1          0          SC

5.  Shows respect for other’s ideas.

            4          3          2          1          0          SC

6.  Respects individual differences.

            4          3          2          1          0          SC

7.  Receptive regarding constructive feedback.

            4          3          2          1          0          SC

8. Organizational skills.

            4          3          2          1          0          SC

9.  Time management skills.

            4          3          2          1          0          SC

10.  Ability to utilize health statistics.

            4          3          2          1          0          SC

11.  Willingness to assume responsibility.

            4          3          2          1          0          SC

12.  Ability to follow through on projects or assignments.

            4          3          2          1          0          SC

13.  Conducts self in a professional manner.

            4          3          2          1          0          SC

14.  Decision making skills.

            4          3          2          1          0          SC

15.  Creativity.

            4          3          2          1          0          SC

16.  Productivity level.

            4          3          2          1          0          SC

17.  Enthusiasm/motivation.

            4          3          2          1          0          SC

18.  Accuracy.

            4          3          2          1          0          SC

19.  Speed or pace.

            4          3          2          1          0          SC

20.  Written communication skills.

            4          3          2          1          0          SC

21.  Choice or selection and use of educational resources.

            4          3          2          1          0          SC

22.  Oral communication skills.

            4          3          2          1          0          SC

23.  Ability to do step-wise planning.

            4          3          2          1          0          SC

24.  Team player.

            4          3          2          1          0          SC

25.  Professional appearance.

            4          3          2          1          0          SC

Please use the back of this sheet for any comments regarding the above if needed.

What are the students’ professional strengths and special aptitudes?

Please list any areas for improvement to further professional development.

What areas of responsibility has the student been given?

What major accomplishments has the student achieved?

Thank you very much.  Please discuss this with the student and mail to:

Dr. Ladona Tornabene                                                 Phone:             218.726.7522

Associate Professor, Health Education              Fax:                 218.726.6243

University of Minnesota Duluth                                   email:               ltornabe@d.umn.edu

1216 Ordean Ct., 110 SpHC

Duluth, MN 55812