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Student’s Practicum Report Form Using this form and additional pages as needed, the student should provide the following information on her/his practicum experience. General Information Student: ___________________________ Dates of Practicum: ____________________ Practicum Information Organization:______________________________________________________________ Address:___________________________________________________________________ __________________________________________________________________________ Preceptor Information Name: ____________________________________ Title:__________________________________ Phone: ________________________________ E-mail: ___________________________________ Brief Description
Below, please give a brief summary of your practicum, evaluating your experience in terms of the following: nature of work, preceptor relationship and supervision, contribution to student’s knowledge and skills, relationship to prior didactic work, whether expectations were met, suggestions for improvement, and suitability of site for other placements. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________
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