CSUF, Dept of Health Science

Student Internship Evaluation/Assessment

Self-Evaluation

Name of Student: ____Thi Do___________________________________________________

Semester of Internship: Fall Spring

Summer

Agency Name: ___Carehouse Healthcare Center

Year: 2015_________

__________________________

Supervisors Name and Title: ___Jennifer Payne, Activities Director___________

Directions:

The assessment process is critical to student growth and development. Your time and
detailed feedback is greatly appreciated.
To assess the skill level for each criterion area, please use the performance evaluation
ratings listed below by placing a check mark in the appropriate column. Please support
your ratings with comments.
Performance Evaluation Ratings
1 - Substantially Exceeded Requirements Clearly and consistently exceeded many
requirements
2 - Exceeded Requirements Clearly exceeded some, and met all other requirements
3 - Met Requirements Clearly met all requirements, or balance minor need for improvement
in one area with exceptional performance in another
4 - Met Some Requirements Met some requirements, but clearly needs to improve in one
or more areas to fully meet requirements
5 - Did Not Meet Requirements Clearly needs significant improvement in one or more
areas to fully meet requirements

Criterion

Rating

Comments

1 2 3 4 5
Interpersonal Relationships

I would welcome customers, greet the staffs, open doors,

lend help to staff members, adapt to the needs of the
patients and customers.

(Interacts with others in a helpful

and informative manner,
adaptability, appreciation for
diversity)

Work Quality (high standards for

work quality, work is accurate,

complete, thorough and well
organized)

Work Quantity (productive,

Every tasks that I was given would be completed

thoroughly. When I have questions, I would always ask.

proficient, utilizes time well,

completes assigned work in a
timely fashion)

Professionalism (demonstrates

Whenever I was done with one task I would pick up the

next task. Whenever I would have to wait for refills for the
coffee and tea, I would help a staff member with another
task.

Whenever a staff needed help, I would always lend a hand.

I would always show up early and I never missed a day
during my time there. I would show up in the required
attire for volunteers.

integrity, dependable, reliable,

good attendance, promptness,
professional personal appearance)

Initiative (works independently,

self-directed, resourceful,
motivated)

Problem Solving (ability to make

I was able to observe nurses and when something is wrong

I would report any issues to my supervisor or administrator.
When nurses needed assistance to get towels, blankets,
pillows for patients I would attend and help them.

I am respectful to the staff nurses and customers/patients. I

would listen and ask questions when I need clarification. I
greet people professionally and clearly.

decisions, ability to recognize and

resolve routine problems/needs,
apply appropriate and creative
solutions)

Communication Skills (Listens

effectively and responds clearly
and directly, oral and written
communication is clear and easy to
understand)

I was comfortable being told what tasks to do and when

customers or patients need help I would take the initiative
to do what I can under professional supervision.

Attitude (Displays drive, energy

and a positive attitude in
completing assigned tasks)

I would greet everyone with a smile. When customers

needed beverages, I would serve them in a positive
attitude. When staff members ask me for assistance I would
positively assist them.

Average rating (grade):

1 (A) 2 (B) 3 (C) 4 (D) 5 (F)

Students Signature: _____Thi Do_______________________ Date:____05/03/15_______________