Site Supervisor Evaluation for Worcester MPH Program

School of Public Health & Health Sciences

University of Massachusetts, Amherst

 

Name of Student: ______________________________________________________

Student’s Division/Department: _Worcester MPH__________

Dates of Practicum: From: _____________ To: ____________ Total Weeks: ____Hours/Wk ____

Name of Practicum Site Supervisor: ___________________________________________________

Practicum Site Supervisor’s Title: _____________________________________________________

Agency, Organization, or Company: ___________________________________________________

Address: _____________________________________________________________

Telephone Number: __________________

Fax Number: ___________________

E-mail Address: ___________________________________________

 

1. Give a brief description of the experiences provided for the student by you and your organization.

 

 

 

2. What type of project did the student perform? Was it completed to your satisfaction?

 

 

 

 

3. What were the positive aspects of the practicum for you and/or your organization?

 

 

 

 

4. What were the challenges of the practicum for you and/or your organization?

 

 

 

 

5. Are there any areas of our student’s educational background that you feel could be added to, improved, or made more complete? What are these?

 

 

6. Indicate your judgment of the student’s work on a scale of 1 (LOW) to 5 (HIGH) by circling the appropriate number next to each item. Circle NA for those items you do not feel qualified to evaluate or for those items that did not apply to this experience.

 

 

 

LOW

AVERAGE

HIGH

Personal Qualities

 

 

 

 

 

 

Ambitious

1

2

3

4

5

NA

Takes the Initiative

1

2

3

4

5

NA

Enthusiastic

1

2

3

4

5

NA

Dependable/Reliable

1

2

3

4

5

NA

 

 

 

 

 

 

 

Relationships with Others

 

 

 

 

 

 

Able to accept suggestions & criticism

1

2

3

4

5

NA

Sensitive to cultural diversity

1

2

3

4

5

NA

Able to work as part of a team

1

2

3

4

5

NA

Respectful of others

1

2

3

4

5

NA

 

 

 

 

 

 

 

Professional Qualifications and Job Performance

 

 

 

 

 

 

Command of technical subject matter

1

2

3

4

5

NA

Able to organize work/time

1

2

3

4

5

NA

Able to express ideas in writing

1

2

3

4

5

NA

Able to communicate ideas orally

1

2

3

4

5

NA

Knowledge of public health topics

1

2

3

4

5

NA

Able to research problems

1

2

3

4

5

NA

Accepts responsibility

1

2

3

4

5

NA

Potential for professional growth

1

2

3

4

5

NA

Overall quality of work

1

2

3

4

5

NA

* Adapted from the University of Oklahoma Health Sciences Center

 

7. Before starting the practicum, the student listed 5 desired competencies he/she wished to acommplish.  Please rank the student on the achievement of these competencies during the practicum.

 

 

 

LOW

AVERAGE

HIGH

Concentration Specific Competency

 

 

 

 

 

 

 

1

2

3

4

5

NA

 

1

2

3

4

5

NA

 

1

2

3

4

5

NA

 

1

2

3

4

5

NA

 

1

2

3

4

5

NA

 

1

2

3

4

5

NA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. What recommendations do you have regarding our Practicum placement policies?

 

 

Practicum Site Supervisor Signature:______________________________________

Date:_______________

 

Submit the completed form to the MPH Practicum Coordinator indicated below. Sending it as an attachment to an email is welcomed.

 

Dr. Jacalyn Coghlin-Strom, MD, MPH
MPH Faculty Director

University of Massachusetts Medical School
Benedict Building – Family Medicine and Community Health
55 Lake Ave North
Worcester MA 01655

 

Email: Jackie.coghlin-strom@umassmed.edu