This form is designed as a component of pre-placement at a practicum or internship field experience site. The student is guided in a self-assessment process that will assist placement coordinators and faculty in determining a student’s readiness to work in a public setting under the supervision of an external (agency rather than university) licensed professional. The form be easily customized to each institution’s curricula.

The form can be used to demonstrate compliance with the CACREP requirement for systematic assessment of students and program objectives (Section 4.A.C. & F-H.).