This form provides a template for use by Site Supervisors to document their screening of interns interviewing for placement at their respective sites. The form provides the opportunity for sites to pinpoint any potential areas of concern and to demonstrate a standardized approach for determining students’ goodness of fit for their agency, or could be used by institutions to document needs for remediation and/or additional preparation for clinical placements.

The form can be used for documenting a component of CACREP requirements for Section 4.F-G and Section 3.C.