2017 Regina Gottlieb Scholarship Evaluation Form

Please rate the dietetic intern who has been under your supervision on the following qualities. A point system will be used to rate each quality. Rating codes are:

5: Outstanding

4: More than satisfactory

3: Satisfactory

2: Needs improvement

1: Unsatisfactory

Intern Name

Evaluated by:

Work Organization Factors to consider: clarity of written assignments, ability to plan the day's schedule and priorities and work within a time frame, clarity of communication.

	5	4	3	2	1
Work Organization

Initiative Factors to consider: self-starter, seeks additional responsibilities, works with minimal supervision

	5	4	3	2	1
Initiative

Responsibility Factors to consider: works independently, punctuality, conforms to established standards.

	5	4	3	2	1
Responsibility

Adaptability Factors to consider: reaction to changes which disrupt routine, adapts to new situations, unusual demands, sudden changes and/or emergencies, reaction to increase in work load or assignments.

	5	4	3	2	1
Adapatability

Teamwork Factors to consider: interpersonal skills, attitude towards supervision and/or instructions received, professionalism, and communications

	5	4	3	2	1
Teamwork

Career Potential

	5	4	3	2	1
Career Potential

Comments

Contact Us

Program Director

Angie Hasemann, MS, RDN, CSP

ajh5j@virginia.edu

434-924-2348

Assistant Program Director

Dana Henry, RDN

dnc4s@virginia.edu

434-982-4925