Wellness - Mid-term Evaluation
This evaluation is designed to provide structural feedback for the Intern, the Internship Supervisor, and the Program Director of Wellness Management on the Intern's progress.

This form is to be completed by the Intern and the Internship Supervisor. Assignments and evaluations should be submitted through this site. If you prefer to mail or fax forms please send them to the Program Director of Wellness Management by the specified due dates. The current address and telephone numbers are:

Dr. Jane Ellery Associate Director Program Director of Wellness Management Fisher Institute for Wellness and Gerontology Ball State University 2000 University Avenue Muncie, Indiana 47306 (765) 285-8259 Main Office (765) 285-8237 Fax

Items with an * indicate a required field.
Today's Date *    
Due Date *    
 
Intern Information
Intern's Name *
Address *
City *
State *
Zip *
Country
Phone *
Fax *
Email *
 
Internship Supervisor Information
Internship Supervisor's Name *
Title *
Internship Site *
Address *
City *
State *
Zip *
Phone *
Fax *
E-Mail *
 
Please select the measure that best describes the intern's ability in each of the following performance categories.
Quality of Work *  Excellent
  Very Good
  Good
  Satisfactory
  Unsatisfactory
  Not Applicable
Quality of Work *  Excellent
  Very Good
  Good
  Satisfactory
  Unsatisfactory
  Not Applicable
Knowledge of Assignments *  Excellent
  Very Good
  Good
  Satisfactory
  Unsatisfactory
  Not Applicable
Professional Conduct *  Excellent
  Very Good
  Good
  Satisfactory
  Unsatisfactory
  Not Applicable
Cooperation *  Excellent
  Very Good
  Good
  Satisfactory
  Unsatisfactory
  Not Applicable
Follows Instructions *  Excellent
  Very Good
  Good
  Satisfactory
  Unsatisfactory
  Not Applicable
Assertiveness *  Excellent
  Very Good
  Good
  Satisfactory
  Unsatisfactory
  Not Applicable
Initiative *  Excellent
  Very Good
  Good
  Satisfactory
  Unsatisfactory
  Not Applicable
Small Group Process *  Excellent
  Very Good
  Good
  Satisfactory
  Unsatisfactory
  Not Applicable
Management Skill *  Excellent
  Very Good
  Good
  Satisfactory
  Unsatisfactory
  Not Applicable
Leadership Skill *  Excellent
  Very Good
  Good
  Satisfactory
  Unsatisfactory
  Not Applicable
Time Management *  Excellent
  Very Good
  Good
  Satisfactory
  Unsatisfactory
  Not Applicable
Communication Skills *  Excellent
  Very Good
  Good
  Satisfactory
  Unsatisfactory
  Not Applicable
 
Please list and describe the following:
Intern's Strengths *
Intern's Areas for Growth *
Intern's Comments *
Intership Supervisor's Comments *
Internship Supervisor has approved worksheet *  Yes
  No
Intern has approved worksheet *  Yes
  No
Date *