This feedback form is one component of our evaluation of the Bethel College Field Instruction Program. The feedback from will be utilized to provide college faculty with feedback regarding their liaison activities and to give the Field Coordinator information with which to assess the success of our field placement program. Field instructors can discuss the rating with the field liaison or send the completed form to the college.

Question Title

* 1. Name of person completed this form:

Question Title

* 2. Date:

Question Title

* 3. Name of Bethel College Faculty Liaison:

Question Title

* 4. Agency and Address

Question Title

* 6. What is the current school year?

Question Title

* 7. Faculty Field Liaison: How frequently has the faculty member met with you for consultation?

Please read each statement below carefully and then check which most clearly corresponds to your opinion.

Question Title

* 8. Site visit before beginning of placement or after several weeks of field placement to assist with placement planning and completion of contract

Question Title

* 9. Assistance with selection and planning of appropriate learning assignments for the student

Question Title

* 10. Facilitation of conflict or problem resolution between the student, field instructor and/or agency

Question Title

* 11. Demonstration of openness to discussing issues that may arise during the field placement

Question Title

* 12. Demonstrated sufficient familiarity with agency policies and procedures to assist with field instruction

Question Title

* 13. Encouragement of mutual responsibility for setting agendas for consultation visits

Question Title

* 14. Provision of constructive feedback about your field teaching abilities

Question Title

* 15. Openness to constructive feedback about his/her liaison activities

Question Title

* 16. Encouragement of a collegial relationship

Question Title

* 17. Demonstrated sensitivity to issues of privacy and confidentiality

Question Title

* 18. Provision of resources, training and/or suggestions for improving your field instruction

Question Title

* 19. Acknowledgement and support of your field teaching responsibilities

Question Title

* 20. Adequate clarification/orientation to the social work department: 

  Satisfactory Unsatisfactory N/A 
Curriculum
Expectation for student's performance
Field instruction policies, forms and procedures
Educational objectives of field instruction

Question Title

* 21. Please make any additional comments:

Question Title

* 22. Field Instructor Signature:

Question Title

* 23. Date of signature:

Date / Time

Question Title

* 24. Field Liaison Signature:

Question Title

* 25. Date of signature:

Date / Time

T