Supervisor _______________________________
Student _________________________________ Date ___________________________________
The agency supervisor is to complete this form upon evaluation of the performance. This form should be completed at the end of the assigned activities for their internship. This report should be sent to the college supervisor within five (5) calendar days after completion. Please mark your response based upon the following scale:
Strongly Agree, Agree, Fair, Disagree, Strongly Disagree, or Not Observed 4 3 2 1 0
Knowedge and Skills Specific to an Athletic Trainer for the internship setting
The student demonstrates the ability to assume activities related to delivery of athletic training services within the context of this setting.
SA A Fair DA SD
4 3 2 1 0 N/O
The student demonstrates the intellectual ability (content knowledge) needed for providing services in this setting.
SA A Fair DA SD
4 3 2 1 0 N/O
The student demonstrates adequate skills in his/her ability to conduct special tests for determining the type of injury or status of the condition.
SA A Fair DA SD
4 3 2 1 0 N/O
The student demonstrates adequate skills in his/her ability to do initial assessment on the patient’s injury condition for the purpose of establishing a starting point for prescribing rehabilitation.
SA A Fair DA SD
4 3 2 1 0 N/O
The student demonstrates adequate skills in his/her ability to do ongoing assessment on the patient’s condition for the purpose of continuing/advancing the patient’s rehabilitation.
70 4 3 2 1 0 N/O
The student demonstrates adequate skills in applying joint mobilization during the rehabilitative process.
SA A Fair DA SD
4 3 2 1 0 N/O
The student demonstrates adequate skills in applying stretching techniques during the rehabilitative process.
SA A Fair DA SD
4 3 2 1 0 N/O
The student demonstrates his/her understanding of rehabilitation protocol for a variety of injury or post-surgical conditions so as to progress a patient through the rehabilitation process
appropriately.
SA A Fair DA SD
4 3 2 1 0 N/O
The student demonstrates proper knowledge for the use of ultrasound during the rehabilitative process.
SA A Fair DA SD
4 3 2 1 0 N/O
The student demonstrates proper knowledge for the use of electrical muscle stimulation during the rehabilitative process.
SA A Fair DA SD
4 3 2 1 0 N/O
The student demonstrates proper knowledge for the application of thermal agents during the rehabilitative process.
SA A Fair DA SD
4 3 2 1 0 N/O
The student demonstrates proper knowledge for the application of cold therapy during the rehabilitative process.
SA A Fair DA SD
4 3 2 1 0 N/O
The student is knowledgeable in contra-indications for injury or post-surgical therapy and exercise.
SA A Fair DA SD
4 3 2 1 0 N/O
The student demonstrates adequate skills for communicating with his/her patients (parents).
SA A Fair DA SD
4 3 2 1 0 N/O
The student demonstrates adequate ability in maintaining records and vital patient information.
SA A Fair DA SD
4 3 2 1 0 N/O
Professionalism and Behavioral Issues
The student shows an active interest in his/her assignments and performs them in a thorough, accurate and neat manner.
SA A Fair DA SD
4 3 2 1 0 N/O
The student demonstrates a desire to learn as much as he/she can about the various learning opportunities available within the setting.
SA A Fair DA SD
4 3 2 1 0 N/O
The student can be relied upon to complete his/her assignments.
SA A Fair DA SD
4 3 2 1 0 N/O
The student demonstrates a willingness to adapt to new or different styles of injury assessment or rehabilitation.
SA A Fair DA SD
4 3 2 1 0 N/O
The student was dressed appropriately and demonstrated professionalism in his/her appearance.
SA A Fair DA SD
4 3 2 1 0 N/O
The student displayed the physical and mental energy and resourcefulness required to get results without the need of urging on the part of his/her supervisor.
SA A Fair DA SD
4 3 2 1 0 N/O
The student was on time and maintained his/her assigned schedule. If there was a problem, the student contacted the supervisor in the appropriate amount of time.
SA A Fair DA SD
4 3 2 1 0 N/O
The student considered all available facts before acting. The student utilized his/her knowledge and skill base to think critically before making decisions.
SA A Fair DA SD
4 3 2 1 0 N/O
72 Additional Comments
Agency Supervisor’s Signature ___________________ Date __________________________
Student’s Signature _________________________ Date __________________________
INTERNSHIP SITE AND SUPERVISORY EVALUATION
Name_________________________________
Date of Completion for REC 477_______________________
Internship Assignment
(location)__________________________________________________________
Name of
Agency_______________________________________________________________________
Address of
Agency_____________________________________________________________________
Name of
Supervisor(s)__________________________________________________________________
PLEASE ANSWER THESE QUESTIONS: GENERAL
1. This internship was a Good Average Poor experience for me. (circle one) 2. State in a single word your internship experience.
3. What did you discover about “yourself” from this experience?
4. Tell me about the “new” things you discovered or learned about people.
5. Describe yourself on your FIRST day of the internship
6. Describe yourself on your LAST day of the internship.
74 1. What particular weakness did you discover about yourself?
2. What was your most rewarding experience?
3. What was your most frustrating experience?
4. Please rate the level of importance the internship experience has had your professional preparation. (circle one)
Very important Moderately important Important Not important Not at all Important
5. Has the internship experience provided for you a view of the profession you did not have before the experience?
Yes No
6. Has the internship experience expanded on your clinical experience and professional preparation beyond that found in the collegiate athletic training setting.
Yes No
PLEASE RESPOND TO THESE QUESTIONS BY CIRCLING THE RESPONSE THAT BEST REFLECTS YOUR VIEW.
1. How would you rate your supervisor ? (circle one in each segment)
A.VERY HELPFUL SOMEWHAT HELPFUL NOT HELPFUL
B.VERY SOMEWHAT NOT
KNOWLEDGABLE KNOWLEDGABEL KNOWLEDGEABEL C.VERY SKILLED SOMEWHAT SKILLED NOT VERY SKILLED 2. Was your supervisor eager to include you in a variety of experiences? YES NO 3. Did your supervisor challenge you to think? YES NO 4. Did your supervisor allow you opportunities to make therapy decisions? YES NO 5. Did your supervisor offer suggestions on how to improve your skills? YES NO 6. Did your supervisor allow you a wide variety of “hands on” experiences? YES NO 7. Were you adequately involved in the total operation of the setting? YES NO 8. Was a detailed “job description” provided and followed? YES NO
COMMENTS:
9. How would you grade your supervisor? A B C D F 10. How would you grade the internship setting? A B C D F 11. Would you personally recommend this agency to a fellow student as a quality internship site?
YES NO COMMENTS:
76 12. How can the “internship experience” (Rec 477) be improved to better serve the needs of future students?
13. What additional experiences or assignments would you recommend be added to the internship?
15. What do you want to be doing five years from today?
A) Personally-
B) Professionally-
C) Educationally-
FINAL SUMMARY REPORT (Please type a detailed summary report of your internship experience).