PLACEMENT SUPERVISOR’S ASSESSMENT FORM
Student Name _____________________________________
Student Number ___________________________________
Placement Facility __________________________________
FORM C
SUPERVISOR TO COMPLETE
Please tick the appropriate box and make comments if appropriate
Competency
Indicator
Professional behaviour
• Arrived on time every day
• Dressed professionally
Communication skills
• Was able to establish rapport and converse
appropriately with staff and patients (if
appropriate)
• Was able to ask staff relevant questions
• Was able to answer relevant questions
• Demonstrated good observational skills at the
placement
• Was able to perform relevant clinical/
laboratory skills at an undergraduate student
level
• Understood and abided by relevant OH&S
policies and guidelines
Background knowledge
Clinical/laboratory skills
Demonstrated safe work
practices

Satisfactory
Unsatisfactory Performance (please tick)
Tick or N/A
Comment
Hours ____________
Supervisor’s Name:_______________________________________
Supervisor’s Signature: ___________________________________Date________________________
GENERAL COMMENTS:
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