Rotation
Supervisor Evaluation (of Intern) Form
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Dietetic Intern's Name: |
Date: |
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Site: |
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Site Preceptor's Name: |
To the Site Supervisor/Preceptor: It is very important that the Dietetic Intern receive formal feedback
during their internship. This Supervisor Evaluation Form serves as a mechanism
by which the Dietetic Internship Director can assess how the Dietetic Intern is
progressing through their experiences. Evaluation
is both of performance and assignments performed at the site. If at any time you
have concerns regarding an intern’s performance, do not hesitate to contact the
Benedictine University Dietetic Internship Director (Julie Moreschi, phone:
630-829-6548) immediately. It is required that the Site Preceptor or their
designee(s) evaluate the student. Thank you for your support of professional
development.
Directions for completing the form: Please select the category that
best describes your judgment of the intern’s performance for that category, and
check the appropriate box. The rating should be a comparison of current
performance as it relates to the performance level needed as an entry-level
dietitian. Please sign and date the form.
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Attendance |
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General Appearance |
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Number of days absent |
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Acceptable |
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Number of times tardy |
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Not Acceptable |
Please refer to this Rating Scale
in making your assessment on the following characteristics:
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4 |
|
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3 |
Above Average (Outstanding) |
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2 |
Average (Satisfactory) |
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1 |
Below Average (Needs Improvement) |
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0 |
Unacceptable (Unsatisfactory) (-) |
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Planning for
assignments. (established goals and objectives,
accepts responsibilities, anticipates unexpected developments, formulates
plans that achieve desired result, organized, manages time efficiently) |
4 |
3 |
2 |
1 |
0 |
|
Decision Making (ability to recognize problems,
ability to make sound decisions under stress, consistently exercises good
judgment, looks at problems objectively) |
4 |
3 |
2 |
1 |
0 |
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Job Knowledge (possesses amount of knowledge necessary
to complete stated objectives, accuracy, observation to detail) |
4 |
3 |
2 |
1 |
0 |
|
Dependability (follows through with assignments,
promptness) |
4 |
3 |
2 |
1 |
0 |
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Initiative (ability to act promptly, willingness to take independent action,
consistency in attaining goals). |
4 |
3 |
2 |
1 |
0 |
|
Resourcefulness (ability to readily determine
alternative courses or plans of action in event of change, inventive, clever,
creative). |
4 |
3 |
2 |
1 |
0 |
|
Adaptability (flexibility,
attitude response to new assignments and change). |
4 |
3 |
2 |
1 |
0 |
|
Industriousness (diligence, effort) |
4 |
3 |
2 |
1 |
0 |
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Enthusiasm |
4 |
3 |
2 |
1 |
0 |
|
Interpersonal Skills (ability to submit ideas and
receive acceptance, tactful, considerate, cooperative, accepts criticism,
sense of humor, professional manner). |
4 |
3 |
2 |
1 |
0 |
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Verbal Communication (quality of oral presentation,
ability to actively participate in discussions and meetings, ability to
listen) |
4 |
3 |
2 |
1 |
0 |
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Written Communication (quality of
reports, ability to use written correspondence effectively, what types of
techniques are used?) |
4 |
3 |
2 |
1 |
0 |
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Site Preceptor's
Signature: |
Date:
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Dietetic Intern's
Signature: |
Date:
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DI Director's Signature: |
Date:
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