Department of Information Science

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Health Informatics Field Experience Form

Date *

Year

Month

Day

Student Last Name *

First Name *

Middle Name / Initial

Internship Site *

Site Supervisor *

Supervisor Phone *

Supervisor Email Address

Internship Site Address *

Student Qualifications *

	Excellent	Good	Fair	Poor	Cannot Rate
General Background Knowledge *	General Background Knowledge - Excellent	General Background Knowledge - Good	General Background Knowledge - Fair	General Background Knowledge - Poor	General Background Knowledge - Cannot Rate
Adaptability *	Adaptability - Excellent	Adaptability - Good	Adaptability - Fair	Adaptability - Poor	Adaptability - Cannot Rate
Readiness to Learn *	Readiness to Learn - Excellent	Readiness to Learn - Good	Readiness to Learn - Fair	Readiness to Learn - Poor	Readiness to Learn - Cannot Rate
Dependability *	Dependability - Excellent	Dependability - Good	Dependability - Fair	Dependability - Poor	Dependability - Cannot Rate
Interpersonal Skills *	Interpersonal Skills - Excellent	Interpersonal Skills - Good	Interpersonal Skills - Fair	Interpersonal Skills - Poor	Interpersonal Skills - Cannot Rate
Judgment *	Judgment - Excellent	Judgment - Good	Judgment - Fair	Judgment - Poor	Judgment - Cannot Rate
Maturity *	Maturity - Excellent	Maturity - Good	Maturity - Fair	Maturity - Poor	Maturity - Cannot Rate
Initiative *	Initiative - Excellent	Initiative - Good	Initiative - Fair	Initiative - Poor	Initiative - Cannot Rate
Accuracy *	Accuracy - Excellent	Accuracy - Good	Accuracy - Fair	Accuracy - Poor	Accuracy - Cannot Rate
Flexibility *	Flexibility - Excellent	Flexibility - Good	Flexibility - Fair	Flexibility - Poor	Flexibility - Cannot Rate

Duties *

(Please comment on the duties or projects which the student undertook and the student’s degree of success in completing the work):

General Evaluation *

(Please comment on any aspect of the student’s performance):

Grade *

(Please recommend a letter grade for the student):

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