IP application spring 2014


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IP application spring 2014

  1. 1. Intermediate Practicum Application After completing please give this to a supervisor to fill out the last page Name (please print): ______________________________________ Supervisor at KAC: _______________________________________ Semester enrolled in PSY 357: ______________________________ Child/children worked with: _________________________________ Current grade in PSY 357: __________________________________ Semester interested in the Advanced Practicum: Fall 2013 _________ Spring2013__________ o I am aware as an Intermediate practicum student I will be required to: o Attend KAC 10 hours a week. o I will be required to read, analyze and apply relevant articles in the field of Behavior Analysis. o I am required to attend at least two Small Group meetings during the semester. Briefly explain your interest in the intermediate 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? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
  2. 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? ---------------------------------------------------------------------------PLEASE FILL OUT EVERYTHING SO THAT WE ARE ABLE TO CONTACT YOU BETWEEN SEMESTERS. Email Address (please print clearly): _____________________________________________ Phone Number: ________________________________ Local Address: _________________________________ ______________________________________________ ______________________________________________ Permanent Address: _____________________________ ______________________________________________ ______________________________________________
  3. 3. Schedule If you know your schedule for next semester please fill out the electronic form attached with this form. Please email it to Kelly.t.stone@wmich.edu NAME: EMAIL: PHONE: WIN: Practicum you're applying for (circle one): Semester you plan on doing the practicum: Intermediate Advanced Summer ____ Fall _____ Spring _____ Please fill in the cells when you are scheduled to be in class or at work. In the cell, please also include the exact start/end times. Monday 8:00 9:00 10:00 11:00 12:00 1:00 Tuesday Wednesday Thursday Friday
  4. 4. 2:00 3:00 4:00 5:00 *Remember you need to do 2 hours/day 5 days/week!! Please circle the shift(s) you are available for 5 days/week 8:00-10:00 10:00-12:00 12:00-2:00 2:00-4:00 Please list the names of the children you worked with: Intermediate Practicum Application (Applicant: Please give this to your monitoring supervisor the one who monitors you) Supervisors must return to Lauren DeClaire Name of applicant: ______________________________________ Child/children worked with: _________________________________ Number of absences at KAC: _____________________________ Please provide comments based on the applicants performance:
  5. 5. 1.) Has the applicant been successful in implementing procedures with their child/children? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 2.) How does the applicant accept feedback? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3.) How well does the applicant interact with Supervisors, other tutors or CDC Staff? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 4.) What stands out about the applicant (either positive or negative)? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 5.) Please provide comments regarding the student’s interpersonal skills? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Recommendation for the Advanced Practicum: [Very strongly] [Recommend] [Recommend with reservations] [Do not] Please rate the student’s skills below: 5 being the best and 1 being the worse Intellectual/Critical Thinking Ability Knowledge of Chosen Field Motivation/Demonstrated Initiative Research Potential 1 2 3 4 5 Not Able to Judge
  6. 6. 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