Fellow Name: Name of Placement: Date Evaluation Completed: Name of Person Completing Form (please include Licensed Psychologist: Yes No highest degree earned): Was this fellow supervised by individuals also under your supervision? Yes No Type of Review: Initial Review Mid-placement Final Review Other (please describe): review Dates of Training Experience this Review Covers: _____ Training Level of Person Being Assessed: Fellow:
Fellow Name: Name of Placement: Date Evaluation Completed: Name of Person Completing Form (please include highest degree earned): Licensed Psychologist: Yes No Was this fellow supervised by individuals also under your supervision? Yes No Type of Review: Initial Review Mid-placement review Final Review Other (please describe): Dates of Training Experience this Review Covers: _____ Training Level of Person Being Assessed: Fellow: