ࡱ> '` bjbj{P{P A::=y0FFFZ>7>7>78v7\8ZnUz9@(@@@BDl3FTTTTTTT$dVhXTEFFA"BFFT@@3(URRRF^8@F@TRFTRRVS@.FQT@n9 P,%x>7IG9T T>U0nUET rYKO(rYQTrYFQTlFFRFFFFFTTsR^FFFnUFFFFZZZ/>7ZZZ>7ZZZ Psychology Trainee Competency Assessment Form Training Year 2009-2010 Trainee:  FORMTEXT        FORMCHECKBOX Sept-Dec  FORMCHECKBOX Dec-Mar  FORMCHECKBOX Mar-June  FORMCHECKBOX June-Aug Supervisor:  FORMTEXT       Site:  FORMDROPDOWN  Assessment Method(s) for Competencies  FORMCHECKBOX Direct Observation  FORMCHECKBOX Review of Written Work  FORMCHECKBOX Videotape  FORMCHECKBOX Review of Raw Test Data  FORMCHECKBOX Audiotape  FORMCHECKBOX Discussion of Clinical Interaction  FORMCHECKBOX Case Presentation  FORMCHECKBOX Comments from Other Staff  Goal: Competence in Professional Conduct, Ethics and Legal Matters Objective: Professional Interpersonal Behavior Professional and appropriate interactions with treatment teams, peers and supervisors, seeks peer support as needed.  FORMCHECKBOX  A Smooth working relationships, handles differences openly, tactfully and effectively.  FORMCHECKBOX  HI Actively participates in team meetings. Appropriately seeks input from supervisors to cope with rare interpersonal concerns.  FORMCHECKBOX  I Progressing well on providing input in a team setting. Effectively seeks assistance to cope with interpersonal concerns with colleagues.  FORMCHECKBOX  E Ability to participate in team model is limited, relates well to peers and supervisors.  FORMCHECKBOX  R May be withdrawn, overly confrontational, insensitive or may have had hostile interactions with colleagues. Objective: Seeks Consultation/Supervision Seeks consultation or supervision as needed and uses it productively.  FORMCHECKBOX  A Actively seeks consultation when treating complex cases and working with unfamiliar symptoms.  FORMCHECKBOX  HI Open to feedback, shows awareness of strengths and weaknesses, uses supervision well when uncertain, occasionally over or under-estimates need for supervision  FORMCHECKBOX  I Generally accepts supervision well, but occasionally defensive. Needs supervisory input for determination of readiness to try new skills.  FORMCHECKBOX  E Needs intensive supervision and guidance, difficulty assessing own strengths and limitations.  FORMCHECKBOX  R Frequently defensive and inflexible, resists important and necessary feedback. Objective: Uses Positive Coping Strategies Demonstrates positive coping strategies with personal and professional stressors and challenges. Maintains professional functioning and quality patient care.  FORMCHECKBOX  A Good awareness of personal and professional problems. Stressors have only mild impact on professional practice. Actively seeks supervision and/or personal therapy to resolve issues.  FORMCHECKBOX  HI Good insight into impact of stressors on professional functioning, seeks supervisory input and/or personal therapy to minimize this impact.  FORMCHECKBOX  I Needs significant supervision time to minimize the effect of stressors on professional functioning. Accepts reassurance from supervisor well.  FORMCHECKBOX  E Personal problems can significantly disrupt professional functioning.  FORMCHECKBOX  R Denies problems or otherwise does not allow them to be addressed effectively.  FORMCHECKBOX  NA Objective: Professional Responsibility and Documentation Responsible for key patient care tasks (e.g. phone calls, letters, case management), completes tasks promptly. All patient contacts, including scheduled and unscheduled appointments, and phone contacts are well documented. Records include crucial information.  FORMCHECKBOX  A Maintains complete records of all patient contacts and pertinent information. Notes are clear, concise and timely. Takes initiative in ensuring that key tasks are accomplished. Records always include crucial information.  FORMCHECKBOX  HI Maintains timely and appropriate records; may forget some minor details or brief contacts (e.g. phone calls from patient), but recognizes these oversights and retroactively documents appropriately. Records always include crucial information.  FORMCHECKBOX  I Uses supervisory feedback well to improve documentation. Needs regular feedback about what to document. Rarely, may leave out necessary information, and occasionally may include excessive information. Most documentation is timely.  FORMCHECKBOX  E Needs considerable direction from supervisor. May leave out crucial information.  FORMCHECKBOX  R May seem unconcerned about documentation. May neglect to document patient contacts. Documentation may be disorganized, unclear or excessively late. Objective: Efficiency and Time Management Efficient and effective time management. Keeps scheduled appointments and meetings on time. Keeps supervisors aware of whereabouts as needed. Minimizes unplanned leave, whenever possible.  FORMCHECKBOX  A Efficient in accomplishing tasks without prompting, deadlines or reminders. Excellent time management skills regarding appointments, meetings and leave.  FORMCHECKBOX  HI Typically completes clinical work/patient care within scheduled hours. Generally on time. Accomplishes tasks in a timely manner, but needs occasional deadlines or reminders.  FORMCHECKBOX  I Completes work effectively and promptly by using supervision time for guidance. Regularly needs deadlines or reminders.  FORMCHECKBOX  E Highly dependent on reminders or deadlines.  FORMCHECKBOX  R Frequently has difficulty with timeliness. Or tardiness or unaccounted absences are a problem.  FORMCHECKBOX  NA Objective: Knowledge of Ethics and Law Demonstrates good knowledge of ethical principles and state law. Consistently applies these appropriately, seeking consultation as needed.  FORMCHECKBOX  A Spontaneously and consistently identifies ethical and legal issues and addresses them proactively. Judgement is reliable about when consultation is needed  FORMCHECKBOX  HI Consistently recognizes ethical and legal issues, appropriately asks for supervisory input.  FORMCHECKBOX  I Generally recognizes situation where ethical and legal issues might be pertinent, is responsive to supervisory input  FORMCHECKBOX  E Often unaware of important ethical and legal issues.  FORMCHECKBOX  R Disregards important supervisory input regarding ethics or law.  FORMCHECKBOX  NA Objective: Administrative Competency Demonstrates a growing ability to accomplish administrative tasks. Prioritizes appropriately. Shows a growing autonomy in management of larger administrative, research or clinical projects.  FORMCHECKBOX  A Independently assesses the larger task to be accomplished, breaks the task into smaller ones and develops a timetable. Prioritizes various tasks and deadlines efficiently and without need for supervisory input. Makes adjustments to priorities as demands evolve.  FORMCHECKBOX  HI Identifies components of the larger task and works independently on them. Needs some supervisory guidance to successfully accomplish large tasks within the timeframe allotted. Identifies priorities but needs input to structure some aspects of task.  FORMCHECKBOX  I Completes work effectively, using supervision time to identify priorities and develop plans to accomplish tasks. Receptive to supervisory input to develop own skills in administration.  FORMCHECKBOX  E Trainee takes on responsibility, then has difficulty asking for guidance or accomplishing goals within timeframe.  FORMCHECKBOX  R Deadline passes without task being done. Not receptive to supervisory input about own difficulties in this process. Goal: Competence in Individual and Cultural Diversity  FORMCHECKBOX  NA Objective: Patient Rapport Consistently achieves a good rapport with patients.  FORMCHECKBOX  A Establishes quality relationships with almost all patients, reliably identifies potentially challenging patients and seeks supervision.  FORMCHECKBOX  HI Generally comfortable and relaxed with patients, handles anxiety-provoking or awkward situations adequately so that they do not undermine therapeutic success.  FORMCHECKBOX  I Actively developing skills with new populations. Relates well when has prior experience with the population.  FORMCHECKBOX  E Has difficulty establishing rapport.  FORMCHECKBOX  R Alienates patients or shows little ability to recognize problems.  FORMCHECKBOX  NA Objective: Sensitivity to Patient Diversity Sensitive to the cultural and individual diversity of patients. Committed to providing culturally sensitive services.  FORMCHECKBOX  A Discusses individual differences with patients when appropriate. Acknowledges and respects differences that exist between self and clients in terms of race, ethnicity, culture and other individual difference variables. Recognizes when more information is needed regarding patient differences and seeks out information autonomously. Aware of own limits to expertise.  FORMCHECKBOX  HI In supervision, recognizes and openly discusses limits to competence with diverse clients.  FORMCHECKBOX  I Has significant lack of knowledge regarding some patient groups, but resolves such issues effectively through supervision. Open to feedback regarding limits of competence.  FORMCHECKBOX  E Is beginning to learn to recognize beliefs which limit effectiveness with patient populations.  FORMCHECKBOX  R Has been unable or unwilling to surmount own belief system to deal effectively with diverse patients.  FORMCHECKBOX  NA Objective: Awareness of Own Cultural and Ethnic Background Aware of own background and its impact on clients. Committed to continuing to explore own cultural identity issues and relationship to clinical work.  FORMCHECKBOX  A Accurately self-monitors own responses to differences, and differentiates these from patient responses. Aware of personal impact on clients different from self. Thoughtful about own cultural identity. Reliably seeks supervision when uncertain.  FORMCHECKBOX  HI Aware of own cultural background. Uses supervision well to examine this in psychological work. Readily acknowledges own culturally-based assumptions when these are identified in supervision.  FORMCHECKBOX  I Uses supervision well to recognize own cultural background and how this impacts psychological work. Comfortable with some differences that exist between self and clients and working well on others. May occasionally deny discomfort with patients to avoid discussing relevant personal and patient identity issues.  FORMCHECKBOX  E Growing awareness of own cultural background and how this affects psychological work. Can make interpretations and conceptualizations from culturally-based assumptions. Responds well to supervision.  FORMCHECKBOX  R Has little insight into own cultural beliefs even after supervision. Goal: Competence in Theories and Methods of Psychological Diagnosis and Assessment  FORMCHECKBOX  NA Total Number of Evaluations Completed this Evaluation Period ______  FORMCHECKBOX  NA Objective: Diagnostic Skill Demonstrates a thorough working knowledge of psychiatric diagnostic nomenclature and DSM multiaxial classification. Utilizes historical, interview and psychometric data to diagnose accurately.  FORMCHECKBOX  A Demonstrates a thorough knowledge of psychiatric classification, including multiaxial diagnoses and relevant diagnostic criteria to develop an accurate diagnostic formulation autonomously.  FORMCHECKBOX  HI Has a good working knowledge of psychiatric diagnoses. Is thorough in consideration of relevant patient data, and diagnostic accuracy is typically good. Uses supervision well in more complicated cases involving multiple or more unusual diagnoses.  FORMCHECKBOX  I Understands basic diagnostic nomenclature and is able to accurately diagnosis many psychiatric problems. May miss relevant patient data when making a diagnosis. Requires supervisory input on most complex diagnostic decision-making.  FORMCHECKBOX  E/R Has significant deficits in understanding of the psychiatric classification system and/or ability to use DSM-IV criteria to develop a diagnostic conceptualization.  FORMCHECKBOX  NA Objective: Psychological Test Selection and Administration Promptly and proficiently administers commonly used tests in his/her area of practice. Appropriately chooses the tests to be administered. Demonstrates competence in administering intelligence tests and MMPI-2.  FORMCHECKBOX  A Proficiently administers all tests. Completes all testing efficiently. Autonomously chooses appropriate tests to answer referral question.  FORMCHECKBOX  HI Occasional input needed regarding fine points of test administration. Occasionally needs reassurance that selected tests are appropriate.  FORMCHECKBOX  I Needs continued supervision on frequently administered tests. Needs occasional consultation regarding appropriate tests to administer.  FORMCHECKBOX  E/R Test administration is irregular, slow. Or often needs to recall patient to further testing sessions due to poor choice of tests administered.  FORMCHECKBOX  NA Objective: Psychological Test Interpretation Interprets the results of psychological tests used in his/her area of practice. Demonstrates competence interpreting intelligence tests and MMPI-2.  FORMCHECKBOX  A Skillfully and efficiently interprets tests autonomously. Makes accurate independent diagnostic formulations on a variety of syndromes. Accurately interprets and integrates results prior to supervision session.  FORMCHECKBOX  HI Demonstrates knowledge of scoring methods, reaches appropriate conclusions with some support from supervision.  FORMCHECKBOX  I Completes assessments on typical patients with some supervisory input, occasionally uncertain how to handle difficult patients or unusual findings. Understands basic use of tests, may occasionally reach inaccurate conclusions or take computer interpretation packages too literally.  FORMCHECKBOX  E/R Significant deficits in understanding of psychological testing, over-reliance on computer interpretation packages for interpretation. Repeatedly omits significant issues from assessments, reaches inaccurate or insupportable conclusions.  FORMCHECKBOX  NA Objective: Report Writing Skills Writes a well-organized psychological report. Answers the referral question clearly and provides the referral source with specific recommendations.  FORMCHECKBOX  A Report is clear and thorough, follows a coherent outline, is an effective summary of major relevant issues. Relevant test results are woven into the report as supportive evidence. Recommendations are related to referral questions.  FORMCHECKBOX  HI Report covers essential points without serious error, may need polish in cohesiveness and organization. Readily completes assessments with minimal supervisory input, makes useful and relevant recommendations.  FORMCHECKBOX  I Uses supervision effectively for assistance in determining important points to highlight.  FORMCHECKBOX  E/R Inaccurate conclusions or grammar interfere with communication. Or reports are poorly organized and require major rewrites.  FORMCHECKBOX  NA Objective: Feedback Regarding Assessment Plans and carries out a feedback interview. Explains the test results in terms the patient and/or caregiver can understand, provides suitable recommendations and responds to issues raised by patient or caregiver.  FORMCHECKBOX  A Plans and implements the feedback session appropriately. Foresees areas of difficulty in the session and responds empathically to patient or caregiver concerns. Adjusts personal style and complexity of language and feedback details to accommodate patient or caregiver needs.  FORMCHECKBOX  HI With input from supervisor, develops and implements a plan for the feedback session. May need some assistance to identify issues which may become problematic in the feedback session. May need intervention from supervisor to accommodate specific needs of patient or family.  FORMCHECKBOX  I Develops plan for feedback session with the supervisor. Presents basic assessment results and supervisor addresses more complex issues. Continues to benefit from feedback on strengths and areas for improvement.  FORMCHECKBOX  E Supervisor frequently needs to assume leadership in feedback sessions to ensure correct feedback is given or to address emotional issues of patient or caregiver.  FORMCHECKBOX  R Does not modify interpersonal style in response to feedback. Goal: Competence in Theories and Methods of Effective Psychotherapeutic Intervention  FORMCHECKBOX  NA Objective: Patient Risk Management and Confidentiality Effectively evaluates, manages and documents patient risk by assessing immediate concerns such as suicidality, homicidality, and any other safety issues. Collaborates with patients in crisis to make appropriate short-term safety plans, and intensify treatment as needed. Discusses all applicable confidentiality issues openly with patients.  FORMCHECKBOX  A Assesses and documents all risk situations fully prior to leaving the worksite for the day. Appropriate actions taken to manage patient risk situations (e.g. escorting patient to ER) are initiated immediately, then consultation and confirmation of supervisor is sought. Establishes appropriate short-term crisis plans with patients.  FORMCHECKBOX  HI Aware of how to cope with safety issues, continues to need occasional reassurance in supervision. Asks for input regarding documentation of risk as needed. Sometimes can initiate appropriate actions to manage patient risk, sometimes needs input of supervisor first. May occasionally forget to discuss confidentiality issues promptly.  FORMCHECKBOX  I Recognizes potentially problematic cases, but needs guidance regarding evaluation of patient risk. Supervision is needed to cope with safety issues; afterwards trainee handles them well. Can be trusted to seek consultation immediately if needed, while patient is still on site. Needs to refine crisis plans in collaboration with supervisor. Needs input regarding documentation of risk. Occasionally needs prompting to discuss confidentiality issues with patient.  FORMCHECKBOX  E Delays or forgets to ask about important safety issues. Does not document risk appropriately. But does not let patient leave site without seeking spot supervision for the crisis. Does not remember to address confidentiality issues, needs frequent prompting. Fear may overwhelm abilities in patient crises.  FORMCHECKBOX  R Makes inadequate assessment or plan, then lets patient leave site before consulting supervisor.  FORMCHECKBOX  NA Objective: Case Conceptualization and Treatment Goals Formulates a useful case conceptualization that draws on theoretical and research knowledge. Collaborates with patient to form appropriate treatment goals.  FORMCHECKBOX  A Independently produces good case conceptualizations within own preferred theoretical orientation, can also draw some insights into case from other orientations. Consistently sets realistic goals with patients.  FORMCHECKBOX  HI Reaches case conceptualization on own, recognizes improvements when pointed out by supervisor. Readily identifies emotional issues but sometimes needs supervision for clarification. Sets appropriate goals with occasional prompting from supervisor, distinguishes realistic and unrealistic goals.  FORMCHECKBOX  I Reaches case conceptualization with supervisory assistance. Aware of emotional issues when they are clearly stated by the patient, needs supervision for development of awareness of underlying issues. Requires ongoing supervision to set therapeutic goals aside from those presented by patient.  FORMCHECKBOX  E/R Responses to patients indicate significant inadequacies in theoretical understanding and case formulation. Misses or misperceives important emotional issues. Unable to set appropriate treatment goals with patient.  FORMCHECKBOX  NA Objective: Therapeutic Interventions Interventions are well-timed, effective and consistent with empirically supported treatments.  FORMCHECKBOX  A Interventions and interpretations facilitate patient acceptance and change. Demonstrates motivation to increase knowledge and expand range of interventions through reading and consultation as needed.  FORMCHECKBOX  HI Most interventions and interpretations facilitate patient acceptance and change. Supervisory assistance needed for timing and delivery of more difficult interventions.  FORMCHECKBOX  I Many interventions and interpretations are delivered and timed well. Needs supervision to plan interventions and clarify interpretations.  FORMCHECKBOX  E/R Most interventions and interpretations are rejected by patient. Has frequent difficulty targeting interventions to patients' level of understanding and motivation.  FORMCHECKBOX  NA Objective: Effective Use of Emotional Reactions in Therapy Understands and uses own emotional reactions to the patient productively in the treatment.  FORMCHECKBOX  A During session, uses own emotional reactions to formulate hypotheses about patients current and historical social interactions, presents appropriate interpretations and interventions. Able to identify own issues that impact the therapeutic process and has ideas for coping with them. Seeks consultation as needed for complex cases.  FORMCHECKBOX  HI Uses own emotional reactions to formulate hypotheses about the patient during supervision sessions. Can identify own issues that impact therapeutic process. Interventions generally presented in the following session.  FORMCHECKBOX  I Understands basic concepts of own emotional reactions. Can identify own emotional reactions to patient. Supervisory input is frequently needed to process the information gained.  FORMCHECKBOX  E When feeling anger, frustration or other intense emotional response to the patient, blames patient at times. Welcomes supervisory input and can reframe own emotional response to the session.  FORMCHECKBOX  R Unable to see issues related to own emotional reactions, even with supervisory input.  FORMCHECKBOX  NA Objective: Group Therapy Skills and Preparation Intervenes in group skillfully, attends to member participation, completion of therapeutic assignments, group communication, safety and confidentiality. If the group is psychoeducational, readies materials for group, and understands each sessions goals and tasks.  FORMCHECKBOX  A Elicits participation and cooperation from all members, confronts group problems appropriately and independently, and independently prepares for each session with little or no prompting. Can manage group alone in absence of co-therapist/supervisor with follow-up supervision later.  FORMCHECKBOX  HI Seeks input on group process issues as needed, then works to apply new knowledge and skills. Needs occasional feedback concerning strengths and weaknesses. Generally prepared for group sessions.  FORMCHECKBOX  I Welcomes ongoing supervision to identify key issues and initiate group interaction. Actively working on identifying own strengths and weaknesses as a group leader. Identifies problematic issues in group process but requires assistance to handle them. May require assistance organizing group materials.  FORMCHECKBOX  E Has significant inadequacies in understanding and implementation of group process. Unable to maintain control in group sufficient to cover content areas. Preparation is sometimes disorganized.  FORMCHECKBOX  R Defensive or lacks insight when discussing strengths and weaknesses. Frequently unprepared for content or with materials. Goal: Competence in Scholarly Inquiry and Application of Current Scientific Knowledge to Practice Objective: Seeks Current Scientific Knowledge Displays necessary self-direction in gathering clinical and research information practice independently and competently. Seeks out current scientific knowledge as needed to enhance knowledge about clinical practice and other relevant areas.  FORMCHECKBOX  A Fully dedicated to expanding knowledge and skills, independently seeks out information to enhance clinical practice utilizing available databases, professional literature, seminars and training sessions, and other resources.  FORMCHECKBOX  HI Shows initiative, eager to learn, beginning to take steps to enhance own learning. Identifies areas of needed knowledge with specific clients. Asks for and responsive to supervisors suggestions of additional informational resources, and pursues those suggestions.  FORMCHECKBOX  I/E Open to learning, but waits for supervisor to provide guidance. When provided with appropriate resources, willingly uses the information provided and uses supervisors knowledge to enhance own understanding.  FORMCHECKBOX  R Unwilling to acquire or incorporate new information into practice. Resists suggestions to expand clinical perspective. Procrastinates on readings assigned by supervisor.  FORMCHECKBOX  NA Objective: Develops and Implements Research Plan Develops and implements plan for research or other professional writing or presentation.  FORMCHECKBOX  A Develops research plan alone or in conjunction with a colleague. Is a full and equal participant in the project.  FORMCHECKBOX  HI Provides substantive input into the plan. Demonstrates ability to execute at least one aspect of the project independently.  FORMCHECKBOX  I/E Provides helpful suggestions regarding design and implementation of a colleagues plan. Provides significant assistance in the accomplishment of the project.  FORMCHECKBOX  R Does not follow-through with responsibilities in development or implementation of plan. Goal: Competence in Professional Consultation  FORMCHECKBOX  NA Objective: Consultation Assessment Performs an assessment of the patient referred for consultation, incorporating mental status exam, structured interview techniques or psychological assessment, as needed, to answer the referral question.  FORMCHECKBOX  A Chooses appropriate means of assessment to respond effectively to the referral question; reports and progress notes are well-organized and provide useful and relevant recommendations with minimal supervisory input.  FORMCHECKBOX  HI Occasional input is needed regarding appropriate measures of assessment and effective write-up of report or progress notes to best answer the referral question  FORMCHECKBOX  I/E Needs continued supervision regarding appropriate assessment techniques to complete consultations as well as input regarding integration of findings and recommendations.  FORMCHECKBOX  R Consultation reports and progress notes are poorly written and/or organized. Fails to incorporate relevant information and/or use appropriate measures of assessment necessary to answer the referral question.  FORMCHECKBOX  NA Objective: Consultative Guidance Gives the appropriate level of guidance when providing consultation to other health care professionals, taking into account their level of knowledge about psychological theories, methods and principles.  FORMCHECKBOX  A Relates well to those seeking input, is able to provide appropriate feedback.  FORMCHECKBOX  HI Requires occasional input regarding the manner of delivery or type of feedback given.  FORMCHECKBOX  I/E Needs continued guidance. May need continued input regarding appropriate feedback and knowledge level of other professionals.  FORMCHECKBOX  R Unable to establish rapport. Supervisor Comments Summary of Strengths:  FORMTEXT       Areas of Additional Development or Remediation, including Recommendations:  FORMTEXT       Conclusions Remedial Work Instructions In the rare situation when it is recognized that a trainee needs remedial work, a competency assessment form should be filled out immediately, prior to any deadline date for evaluation, and shared with the trainee and the director of training. In order to allow the trainee to gain competency and meet passing criteria for the rotation, these areas must be addressed proactively and a remedial plan needs to be devised and implemented promptly. Goal for practicum evaluations All competency areas will be rated at a level of E or higher. No competency areas will be rated as R. Goal for intern evaluations done prior to 12 months All competency areas will be rated at a level of competence of I or higher. No competency areas will be rated as R or E. Goal for intern evaluations done at 12 months At least 80% of competency areas will be rated at level of competence of HI or higher. No competency areas will be rated as R or E. Note: exceptions would be specialty area rotations that would take a more intensive course of study to achieve this level of competency and the major supervisor, training director and trainee agree that a level of I is appropriate for that particular rotation, e.g. a neuropsychology rotation for a general track trainee. Goal for post-doctoral evaluations done prior to 12 months All competency areas will be rated at a level of competence of HI or A. Only areas where the post-doc has no prior experience will be rated I. No competency areas will be rated as R or E. Goal for post-doctoral evaluations done at 12 months At least 80% of competency areas will be rated at level of competence of A. No competency areas will be rated as I, R or E. Note: exceptions would be specialty area rotations that would take a more intensive course of study to achieve this level of competency and the major supervisor, training director and trainee agree that a level of HI is appropriate for that particular rotation, e.g. a neuropsychology rotation for a general track trainee.  FORMCHECKBOX  The trainee HAS successfully completed the above goal. We have reviewed this evaluation together.  FORMCHECKBOX  The trainee HAS NOT successfully completed the above goal. We have made a joint written remedial plan as attached, with specific dates indicated for completion. Once completed, the rotation will be re-evaluated using another evaluation form, or on this form, clearly marked with a different color ink. We have reviewed this evaluation together. Training Director __________________________________________________ Date ___________ Clinical Supervisor __________________________________________________ Date ___________ Trainee Comments Regarding Competency Evaluation (if any): I have received a full explanation of this evaluation. I understand that my signature does not necessarily indicate my agreement. Trainee ____________________________________ Date ___________     Page  PAGE 5 of  NUMPAGES 9 Competency Ratings Descriptions NA Not applicable for this training experience/Not assessed during training experience A Advanced/Skills comparable to autonomous practice at the licensure level. Rating expected at completion of postdoctoral training. Competency attained at full psychology staff privilege level, however as an unlicensed trainee, supervision is required while in training status. HI High Intermediate/Occasional supervision needed. A frequent rating at completion of internship. 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