1. Advanced Practicum Application
After completing please give this to a supervisor to fill out the last
page
Name (please print): ______________________________________
TA at Croyden (circle one): Joe Brighid Dru Kelly
Semester enrolled in PSY 357: ______________________________
Child/children worked with: _________________________________
Current grade in PSY 357: __________________________________
Semester interested in the Advanced Practicum:
Summer ‘11 Fall ‘10 Spring ’11
o I am aware as an Advanced practicum student I will be required to:
o Attend Woodsedge 10 hours a week.
o Attend one-to-one meetings with assigned case coordinator and a BCBA
supervisor to discuss assigned children.
o Assist a case coordinator with many of the tasks involved in this position
which will require additional hours beyond the onsite time.
Briefly explain your interest in the advanced practicum. What do you hope to gain
from the experience What qualifications do you have? Why do you deserve an
opportunity over other applicants and what contributions can you make to the
practicum?
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2. Are you interested in graduate school at Western Michigan University?
Not interested 1 2 3 4 5 Very interested
How interested are you in graduate training in behavior analysis?
Not interested 1 2 3 4 5 Very interested
PLEASE FILL OUT OTHER SIDE
Questions or comments should be emailed to? at:
WIN #:_____________________
Are you a BRSS student? ________
If yes, which system or project are you working on and who supervises you?
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PLEASE FILL OUT EVERYTHING SO THAT WE ARE ABLE TO CONTACT
YOU BETWEEN SEMESTERS.
Email Address (please print clearly):
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Phone Number: ________________________________
Local Address: _________________________________
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Permanent Address: _____________________________
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3. Advanced Practicum Application
(Applicant: Please give this to your monitoring supervisor (the one who monitors
you at Woodsedge)
Supervisors must return to
Name of applicant: ______________________________________
Child/children worked with: _________________________________
Number of absences at Croyden: _____________________________
Please provide comments based on the applicants performance:
1.) Has the applicant been successful in implementing procedures with
their child/children?
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2.) How does the applicant accept feedback?
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3.) How well does the applicant interact with Supervisors, TAs, and
Croyden Staff?
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4.) What stands out about the applicant (either positive or negative)?
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5.) Please provide comments regarding the student’s interpersonal skills?
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4. 6.) What stands out about the applicant (either positive or negative)?
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Recommendation for the Advanced Practicum:
[Very strongly] [Recommend] [Recommend with reservations] [Do not]
Please rate the student’s skills below:
Not
Able to
5 being the best and 1 being the worse 1 2 3 4 5 Judge
Intellectual/Critical Thinking Ability
Knowledge of Chosen Field
Motivation/Demonstrated Initiative
Research Potential
Teaching Potential
Social Skills
Work Habits
Originality/Creativity/Innovative Thinking
Problem Solving/Abstract Reasoning Ability
Oral Communication Skills
Written Communication Skills
Leadership Potential
Emotional Stability/Personal Maturity/Evaluation of Self
Professionalism Under Stressful Situations
Openness to Feedback
Acceptance of Responsibility
Ability to Work Independently