Student Job Placement Evaluation Form printable pdf download

Student Job Placement Evaluation Form

STUDENT JOB PLACEMENT EVALUATION FORM

Please complete this form to describe your position for 2009-2010

Your Name:

_______________________________________ Date: ______________

Position Title:

___________________________________________________________

Agency Name:

___________________________________________________________

Address:

___________________________________________________________

Phone:

___________________________________________________________

Start Date:

_______________________ Projected End Date: ___________________

Position Type:

Research _______

Clinical _______

Teaching _______

Average hours per week:

___________________

Salary: ___________________

Fringe benefits (e.g. vacation, insurance, tuition waiver, etc.): ___________________________

Primary Supervisor: ___________________________________________________________

Secondary Supervisor: __________________________________________________________

PLEASE DESCRIBE THE TYPICAL DUTIES OF YOUR POSITION

a. Clinical Assessment (e.g., tests administered, interpretations, write-ups, case

presentation):

______________________________________________________________________

b. Psychotherapy (e.g., number and type o clients, amount and type of client contact, group

vs. individual):

______________________________________________________________________

c. Case Conference/Staff Meetings (e.g., format, frequency):

______________________________________________________________________

Student Job Placement Evaluation Form