Community Practicum I-II MY Review Form

Community Practicum

Mid-Year Review
Campus code
Student:
Student's Email:
example@example.com
Year/ Practicum Level:
Academic year:
Community:
Practicum Supervisor:
Practicum Supervisor's Email:
example@example.com
Practicum Coordinator/ Class Advisor:
Practicum Coordinator/ Class Advisor Email (please only list one email):
example@example.com
In preparation for your mid-year review, please review your completed learning agreement and have a copy of it on hand to refer to during your meeting. Attach additional pages if needed. Unless specifically directed to do so, do not leave any field blank.
1. Primary responsibilities: Describe any significant changes to your practicum responsibilities, including to the setting, schedule, or goals. If there are no significant changes to report, write N/A
2. Reflection and self-assessment: Comment briefly on your experience in the practicum so far, in general and especially with regard to your primary learning goals and the capacity areas you are developing. In which aspects or ways do you feel confident, appropriately supported, challenged, or fulfilled?
In which aspects/ ways do you feel unsure, overly challenged, or unfulfilled?
3. Feedback (completed by your Practicum Supervisor): Based on your observations, experience, input from colleagues (with and without support needs), and the Student's own self-reflection, what advice or direction can you provide, in general, and specifically with regard to the learning goals and the Student's focused activity. Include any concerns or issues that need to be referred to the Practicum Coordinator/ Class Advisor for further action. If attention or remediation is needed, indicate the date the Practicum Coordinator/ Class Advisor was notified in the field below and attach additional documentation such as a remediation plan.
Mark One (MUST be completed by Practicum Supervisor):
By signing this Mid-Year Review Form, you confirm the information above is an accurate reflection of your conversation. Once completed and signed, the Program Administrator will receive a copy automatically and will file in your student record. You, the student, will also be emailed a copy and should retain it for reference throughout the practicum, and specifically during your Final Review conversation.
Student Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Practicum Supervisor Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Program Administrator email:
example@example.com
Should be Empty: