Form B.1
EVALUATION REPORT
CLINICAL SUPERVISOR OF RECORD
INSTRUCTIONS:
 This form must be completed on a computer, the space will expand as needed. Hand-written forms will
not be accepted.
 This form must be completed by the Clinical Supervisor of Record every 6 months.
 Cumulative totals should reflect totals for all reports, including this one.
 Please provide detailed responses to the questions wherever possible to give a complete picture of the
supervisory relationship and the supervisee’s development.
 Form must be signed and dated
 The clinical registry applicant tracking sheet attached to this report must be updated with each
evaluation. This tracking sheet should incorporate all hours from other clinical supervisors for the
reporting period.
 Any changes to the supervision provided must be reflected on the Supervisee’s Supervision Plan
and submitted to the Clinical Committee for approval.
Supervisee’s name:
Supervisee’s place of employment:
Name of clinical supervisor of record:
Evaluation number:
(If final, please indicate)
Date supervision plan first
implemented:
Names of other clinical or employment
supervisor(s)
REPORTING PERIOD
From:
To:
If more than one supervisor is involved, please describe frequency of meetings between the supervisors
and any issues that have arisen due to the supervision format.
DIRECT CLINICAL PRACTICE HOURS
Number of direct clinical practice hours for this
reporting period:
Number of face-to-face client hours for this
reporting period:
Cumulative Total
/1600
Cumulative Total
/900
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Form B.1
CLINICAL SUPERVISOR OF RECORD
Number of live sessions or audio or videotapes of
the Supervisee’s work reviewed for this reporting
period:
INDIVIDUAL SUPERVISION (AS APPROVED IN THE SUPERVISION PLAN)
Total number of individual supervision hours this
reporting period:
GROUP SUPERVISION (AS APPROVED IN THE SUPERVISION PLAN)
Total number of group supervision hours this
reporting period:
Cumulative Total
/10
Cumulative Total
/50
Cumulative Total
The Clinical Committee has adopted the definitions of progressive levels of professional competence as
established by the American Board of Examiners in Clinical Social Work, as stated below.
* For information on how to interpret these definitions go to: http://www.abecsw.org/images/Competen.PDF.
Please read the definitions prior to completing the evaluation.
(1) Postgraduate Practice Level (MSW Level)
The MSW level provides a basic preparation for clinical social work practice. The typical MSW curriculum
provides students with an overall orientation to the field of professional social work; a basic grounding in
theories of social work practice and application of these theories to practice; an exposure to generic practice
methods; and a foundation in the values and ethics of the profession.
 Expand the diversity of their clinical experiences
 Increase their knowledge of the legal and ethical parameters of practice
 Enhance their practice skills
 Learn to identify clients who are at risk and to intervene appropriately
 Augment their repertoire of practice theories and methods
 Mature in the professional use of self
 Increase their ability to differentiate clinical observations from inferences
 Achieve integrity of their professional beliefs
 Increase confidence in their clinical judgment through self study of practice and clinical supervision.
 Define their professional stance vis-à-vis the reality of the practice environment
 Understand and accept their practice limitations
 Develop a concept and a plan for their future professional development
(2) Autonomous Practice Level
Autonomous practice is practice that is not under clinical supervision—whether inside or outside an agency
structure. This level of professional development reflects mastery of practice competencies. Autonomous
practitioners are expected to be able to assume clinical responsibility for the diagnosis, assessment and
treatment of their clients, deciding for themselves when consultation is necessary. Achievement of the following
skills indicates that the practitioner has reached the autonomous practice level:
 Provides adequate clinical diagnoses and biopsychosocial assessments
 Performs short- and/or long-term interventions
 Establishes treatment plans with measurable goals
 Adapts interventions to maximize client responsiveness
 Demonstrates competence in clinical risk assessment and intervention
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Form B.1





Recognizes when personal issues affect clinical objectivity
Recognizes and operates within own practice limitations
Seeks consultation when needed
Refers to sources of help when appropriate
Practices within established ethical and legal parameters
(3) Advanced Practice Level
The advanced practice level required a five-year minimum of practice experience beyond graduation as an
MSW, plus the achievement of the autonomous practice level. Advanced clinical social workers are expected to
have reached the full integration of a professional self and have affirmed their professional role and identity; to
recognize that the relationship between theory and practice is often problematic and that theories of
development and practice skills require constant emendation (Fook, Ryan and Hawkins, 1997). Advanced
clinical social workers are expected to have mastered the skills required for autonomous practice with diverse
populations, and may have also developed mastery of specialized areas of clinical practice. Additionally,
advanced clinical social workers may have acquired the skills to supervise, consult, teach, and otherwise
contribute to the professional development of colleagues. Advanced practitioners demonstrate the following:
 Increased depth and breadth of practice skills
 Independent competence with diverse diagnostic groups
 Ability to adapt core knowledge to unique needs of client and milieu
 Clear definition of limitations in level of expertise and scope of practice
 Continued participation in direct practice activities
 Ongoing motivation for learning from practice experience
 Commitment to and implementation of continuing professional education and development
 Maintenance of highest level of ethical standards for the profession
 Specialization in one or more areas of expertise
 Expertise in participating in the professional development of colleagues (through mentorship,
supervision and other modes of teaching)
 Leadership in developing and expanding intervention strategies
 Leadership in defining and attending to professional issues
 Ability to expand the conceptual knowledge of the profession
*Used with permission
The Clinical Social Work Register is intended to identify autonomous clinical practitioners. Where would you
place this Supervisee?
1 = Post-graduate practice level
2 = Autonomous practice level
3 = Advanced practitioner
Using the same scale of 1 to 3 shown above, please rank the Supervisee in each of the following categories in
their current clinical practice:
Practice Indicator
1
2
3
No opportunity
to observe
1.Provides adequate clinical diagnoses and biopsychosocial assessments
2.Performs short- and/or long-term interventions
3. Establishes treatment plans with measurable goals
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Form B.1
4. Adapts interventions to maximize client responsiveness
5. Demonstrates competence in clinical risk assessment and intervention
6. Recognizes when personal issues affect clinical objectivity
7. Recognizes and operates within own practice limitations
8. Seeks consultation when needed
9. Refers to sources of help when appropriate
10. Practices within established ethical and legal parameters
11. Mature in professional use of self
12. Able to differentiate clinical observations from inferences
13. Demonstrates integrity with professional values/beliefs
14. Demonstrates self-confidence in practice
15. Able to identify needs and plan for professional development
16. Able to work with diverse groups/populations
17. Demonstrates appropriate record-keeping and file management skills
18. Uses literature and other resource materials to enhance practice
19. Works collaboratively with other professionals to meet the client’s best
interest
20. Integrates clinical theory into practice meaningfully
21. Manages professional boundaries appropriately
1. Briefly describe the Supervisee’s professional growth in the last six months with reference to the
learning goals in the supervision plan:
2. Briefly describe goals for the Supervisee’s professional growth in the next six months (not
required if this is the Final Evaluation and the Supervisee is approved to write the clinical exam):
3. Do you have any concerns about the Supervisee being eventually admitted to the Clinical Social
Work Registry? Yes or no, please briefly describe:
4. To be completed ONLY if this is the Supervisee’s Final Evaluation
a) In my opinion, the Supervisee is ready for autonomous practice, yes or no, please briefly
describe:
b) I approve the Supervisee to write the
clinical exam:
Yes 
No 
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Form B.1
Clinical Supervisor of
Record Signature:
Date:
Supervisee’s Signature:
Date:
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Form B.1
Clinical Registry Applicant Tracking Sheet
*This form must be completed and submitted with each evaluation
Name:
RSW:
Email:
Initial Application
Date
Submitted:
Approved
Date
Direct Practice Hours (1600
Supervision SOR Hours
Other Supervision
Total)
(up to 50 hours)
Other
Eval # Date Direct
Face
Direct
Individual
Case
Group
Supervision
Practice
to
Supervision/Live
Sup
Consult provided Individual
Hours
Clinical
Hours
Face
Sessions or
/40
provided by SOR
Grand
/700
Client
Audio Video
by
or OCS Supervision Total/100
Hours
Sessions/10
CSOR
hours
/900
or OCS
Interim
#1
Subtotal
Interim
#2
Subtotal
Interim
#3
Subtotal
Interim
#4
Subtotal
Interim
#5
Subtotal
Final
Total
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