Please print this form by sending to your local printer.
Semester(CircleOne): |
Fall |
Spring |
Summer |
Year: |
Student's
Name |
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Address |
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Phone |
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SS# |
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Major |
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Placement
Agency |
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Supervisor |
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Agency
Address |
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Agency
Phone |
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Date |
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Field Supervisor Report: To be completed by supervisor listed above
Hours
completed by student (per week) |
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Total
hours during the semester |
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Practicum
activities and duties |
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Please
describe the nature of the student's activities and
responsibilities with your agency (Use additional page if necessary) |
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Please comment on the extent to which you feel the student
has fulfilled his/her commitment to your agency (Use additional page if necessary) |
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Recommend
Grade: (Circle one) |
A |
A- |
B+ |
B |
B- |
C+ |
C |
C- |
D+ |
D |
D- |
F |
|
Overall
rating of placement (Circle one) |
Excellent -------- Good ----------- Fair ---------- Poor |
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Comments |
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Signature
of Field Supervisor |
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Date |
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If you need further information regarding Practicum opportunities contact:
Dr. Michael Caserta, Practicum Coordinator
587 College of Nursing, 581-3572
michael.caserta@nurs.utah.edu
