Teacher:	School:

Grade Level/Subject:	Date:

U=Unsatisfactory	NI=Needs Improvement	P=Proficient	E=Excellent

Domain 1 – Planning and Preparation (circle domain rating)	U	NI	P	E
1a. Knowledge of Regulatory Procedures and Skill in Delivery of School Social Work Services
1b. Knowledge and Understanding of Child and Adolescent Development, Influence of Culture, Background, and Social Emotional Characteristics
1c. Establishing Goals for Social Work Services
1d. Designing Social Work Services Which May Include Individual and Small Group Sessions, In-Class Activities and Crisis Intervention
1e. Designing Student Social Work Plan and Assessment
Domain 2 - The Environment (circle domain rating)	U	NI	P	E
2a. Creates an Environment of Respect and Rapport
2b. Establishing a Culture for Positive Mental Health Throughout the School
2c. Managing Social Work Practice and Organizing Physical Space
2d. Managing the Social Learning Process
Domain 3 – Delivery of Service (circle domain rating)	U	NI	P	E
3a. Communicating With Students
3b. Using Questioning and Discussion Techniques
3c. Engaging Students
3d. Using Assessment
3e. Demonstrating Flexibility and Responsiveness
Domain 4 – Professional Responsibility: (circle domain rating)	U	NI	P	E
4a. Reflecting on Practice
4b. Maintaining Accurate Records and Documentation
4c. Communicating with Families
4d. Growing Individually and Collectively as a Professional
4e. Showing Professionalism