School of Education and Human Development School Psychology Program 8 Bailey Hall Gorham, ME 04038 Phone: 207-780-5300 TTY: 207-780-5646 FAX: 207-780-5708 Form M1: Matriculated Student Annual Report Cover Sheet Student: Address: Phone number(s): E-mail: Psy.D. program faculty advisor: Year admitted to School Psychology Program: Advisor: Total Credits taken so far: Anticipated year(s) for internship: - school year(s) on a ____ full or ____ part-time basis Attach the following documents to this cover sheet: Transcript (unofficial is fine) with all grades, including those for most recent semester Pages 2-7 of this Form Submit this cover sheet and the required documents to the address at the top of this form no later than st May 1 for the previous academic year. If you have questions about how to complete your Annual Student Report, contact your advisor. School of Education and Human Development School Psychology Program 8 Bailey Hall Gorham, ME 04038 Phone: 207-780-5300 TTY: 207-780-5646 FAX: 207-780-5708 Form M1: Matriculated Student Annual Report, page 2 Student: Rating Scale: Remediation Plan Minimal Remediation In Progress Meets Expectations Exceeds Expectations Demonstrates Excellence 1 2 3 4 5 6 Using the above rating scale, rate your progress in each of the following areas. Your adviser will complete the last column for faculty rating and return this form to you with comments. ACADEMIC PROGRESS Area Class Participation Student Rating Oral Presentations Written Communication and Assignments Other Additional Comments: Comments Goals/Suggestions for Future Faculty Rating Form M1: Matriculated Student Annual Report, page 3 Student: Rating Scale: Remediation Plan Minimal Remediation In Progress Meets Expectations Exceeds Expectations Demonstrates Excellence 1 2 3 4 5 6 Using the above rating scale, rate your progress in each of the following areas. Your adviser will complete the last column for faculty rating and return this form to you with comments. PROFESSIONAL SKILLS Area Completes work in a timely manner Student Rating Punctuality Assistantship Responsibilities Other Additional Comments: Comments Goals/Suggestions for Future Faculty Rating Form M1: Matriculated Student Annual Report Cover Sheet, page 4 Student: Rating Scale: Remediation Plan Minimal Remediation In Progress Meets Expectations Exceeds Expectations Demonstrates Excellence 1 2 3 4 5 6 Using the above rating scale, rate your progress in each of the following areas. Your adviser will complete the last column for faculty rating and return this form to you with comments. PRACTICA AND FIELD EXPERIENCES Area Student Rating Test Administration Test Interpretation Report Writing Counseling Children Counseling Adults Consulting Other Additional Comments: Comments Goals/Suggestions for Future Faculty Rating Form M1: Matriculated Student Annual Report Cover Sheet, page 5 Student: Rating Scale: Remediation Plan Minimal Remediation In Progress Meets Expectations Exceeds Expectations Demonstrates Excellence 1 2 3 4 5 6 Using the above rating scale, rate your progress in each of the following areas. Your advisor will complete the last column for faculty rating and return this form to you with comments. PERSONAL AND PROFESSIONAL DEVELOPMENT SKILLS Area Using Feedback Non-Defensively Student Rating Recognizing Strengths and Weaknesses Handing Frustration and Ambiguity Appropriate Assertiveness Skills Sensitivity and Tolerance for Other Viewpoints Taking Appropriate Initiative for Improving Skills Awareness of and Sensitivity to Cultural Differences Additional Comments: Comments Goals/Suggestions for Future Faculty Rating Form M1: Matriculated Student Annual Report Cover Sheet, page 6 Student: STRENGTHS AND AREAS IN NEED OF IMPROVEMENT Strengths: Advisor comments on strengths: Areas in Need of Improvement: Advisor comments on areas in need of improvement Overall Progress in the Program: Student: Needs Improvement Satisfactory Good Excellent Advisor: Needs Improvement Satisfactory Good Excellent Student Signature: _______________________________________________ Date: ______________ Advisor Signature: _______________________________________________ Date: ______________