Weekly Planning Form

Dates: ___________________________

Week # ______________

Step I: Student assessment of previous week’s goals. Provide supporting examples and/or feedback

regarding performance where possible. (Ignore this section if this is your first week of the clinical

assignment).

Knowledge Goal 1:

Skills Goal 2:

Affective Goal 3:

Step II: Clinical Instructor feedback and suggestions for improvement (clinical instructor should

contact DCE if student is not progressing in a reasonable fashion regarding weekly goals):

Step III: Mutually agreed upon goals for the Upcoming Week:

Knowledge Goal 1:

Skills Goal 2:

Affective Goal 3:

Student’s Signature: __________________________________________________________

Clinical Instructor’s Signature: _________________________________________________

Revised 5/1/2007

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