Please use this form to provide feedback to CBL staff, Community Mentors and Faculty about the CBL student you are supervising this semester. Community Partner Information Community Partner Supervisor Name * Community Agency/Program * Email * Student Information Student First Name * Student Last Name * Semester * Fall Spring Summer Year * Student Course Associated with Placement Ex. CBL 100: Introduction to Community Based Learning Total Hours (student has completed to date) * Evaluate Student Please evaluate the CBL student * pooraveragegoodexcellentN/A Reliability: Did the student arrive on time and stay entire time on scheduled visit days? * Reliability: Did the student arrive on time and stay entire time on scheduled visit days? - poor Reliability: Did the student arrive on time and stay entire time on scheduled visit days? - average Reliability: Did the student arrive on time and stay entire time on scheduled visit days? - good Reliability: Did the student arrive on time and stay entire time on scheduled visit days? - excellent Reliability: Did the student arrive on time and stay entire time on scheduled visit days? - N/A Ability of student to notify you in advance if he/she could not attend placement and schedule a time to make up hours? * Ability of student to notify you in advance if he/she could not attend placement and schedule a time to make up hours? - poor Ability of student to notify you in advance if he/she could not attend placement and schedule a time to make up hours? - average Ability of student to notify you in advance if he/she could not attend placement and schedule a time to make up hours? - good Ability of student to notify you in advance if he/she could not attend placement and schedule a time to make up hours? - excellent Ability of student to notify you in advance if he/she could not attend placement and schedule a time to make up hours? - N/A Ability of student to adapt to the agency environment * Ability of student to adapt to the agency environment - poor Ability of student to adapt to the agency environment - average Ability of student to adapt to the agency environment - good Ability of student to adapt to the agency environment - excellent Ability of student to adapt to the agency environment - N/A Ability of student to be resourceful * Ability of student to be resourceful - poor Ability of student to be resourceful - average Ability of student to be resourceful - good Ability of student to be resourceful - excellent Ability of student to be resourceful - N/A Willingness to take initiative * Willingness to take initiative - poor Willingness to take initiative - average Willingness to take initiative - good Willingness to take initiative - excellent Willingness to take initiative - N/A Ability of the student to follow directions/instructions * Ability of the student to follow directions/instructions - poor Ability of the student to follow directions/instructions - average Ability of the student to follow directions/instructions - good Ability of the student to follow directions/instructions - excellent Ability of the student to follow directions/instructions - N/A Ability of the student to demonstrate patience * Ability of the student to demonstrate patience - poor Ability of the student to demonstrate patience - average Ability of the student to demonstrate patience - good Ability of the student to demonstrate patience - excellent Ability of the student to demonstrate patience - N/A Ability to cooperate with peers, support staff and clients/guests * Ability to cooperate with peers, support staff and clients/guests - poor Ability to cooperate with peers, support staff and clients/guests - average Ability to cooperate with peers, support staff and clients/guests - good Ability to cooperate with peers, support staff and clients/guests - excellent Ability to cooperate with peers, support staff and clients/guests - N/A Ability to accept and utilize criticism * Ability to accept and utilize criticism - poor Ability to accept and utilize criticism - average Ability to accept and utilize criticism - good Ability to accept and utilize criticism - excellent Ability to accept and utilize criticism - N/A OVERALL performance of the student at the agency * OVERALL performance of the student at the agency - poor OVERALL performance of the student at the agency - average OVERALL performance of the student at the agency - good OVERALL performance of the student at the agency - excellent OVERALL performance of the student at the agency - N/A OVERALL attitude of the student * OVERALL attitude of the student - poor OVERALL attitude of the student - average OVERALL attitude of the student - good OVERALL attitude of the student - excellent OVERALL attitude of the student - N/A What specific projects/tasks were completed by the student during his/her placement with your agency? Comments Additional Comments Leave this field blank Submit
