Date:

Student:

Student ID#:

Course name:

Course #:

Instructor:

Site name:

Site address:

City/State/Zip:

Supervisor/evaluator:

Phone:

Please rate the student in the following areas.
1 is Poor and 5 is Outstanding:

Dependability: 1  2  3  4  5

Attendance: 1  2  3  4  5

Punctuality: 1  2  3  4  5

Participation: 1  2  3  4  5

Overall performance: 1  2  3  4  5

Comments: (Skills developed, ability to integrate theory and practice, contributions to agency, interpersonal skills, overall work ethic, etc.)