PROVIDER'S EVALUATION OF INTERN, Page 2 of 2

II. GENERAL WORK BEHAVIOR:  Please assess the intern's general work behavior in terms of the following characteristics.  Please mark the appropriate column.

  Don't Know Poor Fair Good Excellent
Dependability          
Follows Instructions          
Accepts Responsibility          
Shows Initiative          
Interest in Work          
Works Well with Others          
Organizes Work          
Perserverance on Task          

III. AREAS OF IMPROVEMENT: If you were considering this individual for a job, what improvements in work habits, interpersonal skills, and job skills would you want to see him/her overcome before being hired?

 
 
 
 

IV. OVERALL PERFORMANCE: If you were to assign a letter grade for this intern's overall performance, what grade would you assign? Please circle one.

A(=excellent)   B    C   D   F(=failure)

Print Supervisor's Name:
 
Signature:
 		 Date: