New York State Certified Peer Worker
Supervisor Practicum/Work Experience Evaluation Form

Directions for supervisors completing this evaluation:

This form should be completed by the direct supervisor of an individual seeking Certification as NYS Peer Worker. Please review all directions carefully.

Applicant Practicum Information

Name of Peer Worker Seeking Certification:
Name of Supervisor:
Name of Agency:
Title Held by Peer Worker:
Responsibilities Carried Out:

Please indicate the dates the peer worker has provided services under your supervision and the numbers of hours of work he/she completed under your supervision.

Start Date:
End Date:
Hours Completed:

Did the peer worker complete a minimum of 500 hours of work? Yes No

Did the peer worker complete all 500 hours of work under your supervision?
Yes No

If no- Please provide the supervisor’s name, former agency, and number of hours for where the peer worker completed the first portion of hours of his/her practicum(If he/she received additional hours of work experience to complete the 500 hours with a different supervisor at a different agency, you will need to confirm with the former supervisor/agency that the peer worker completed the additional hours prior to working with you.):

Name:
Agency:
Hours Completed:

Please select the Track(s) you are evaluating the peer worker on:
HIV | HCV | HR | PREP | Criminal Justice * (you must select at least one)

Practicum Evaluation

For each of the areas outlined in items 1-8, please provide a rating by checking the box that best corresponds with your assessment and provide written comments to substantiate your rating.

1. Ability to learn and openness to supervisor’s feedback
Unacceptable Needs Improvement Satisfactory Exemplary

Comments:

2. Quality of work
Unacceptable Needs Improvement Satisfactory Exemplary

Comments:

3. Level of productivity/ work habits
Unacceptable Needs Improvement Satisfactory Exemplary

Comments:

4. Ability to establish positive rapport with clients
Unacceptable Needs Improvement Satisfactory Exemplary

Comments:

5. Ability to work well with other professionals
Unacceptable Needs Improvement Satisfactory Exemplary

Comments:

6. Attendance and punctuality
Unacceptable Needs Improvement Satisfactory Exemplary

Comments:

7. Ability to follow all agency policies and procedures
Unacceptable Needs Improvement Satisfactory Exemplary

Comments:

8. Overall Rating
Unacceptable Needs Improvement Satisfactory Exemplary

Comments:

Evaluation of Competencies

Prior to beginning this online evaluation form, we suggest that you review the list of Core Competencies for the track the peer worker you are evaluating is applying (HIV/HCV/HR), available here: http://hivtrainingny.org/Home/PeerCertification

Please Note: If the peer worker is applying for certification in more than one track, you will need to provide feedback for 25 competencies from each track for which you have supervised them, in addition to the General Competencies. Only evaluate the competencies you have observed. If you have not supervised the peer in a role that has duties related to a certain track (i.e., you supervise them in an HIV Peer Navigator Role, but they also have work experience as a Harm Reduction Educator Capacity, for which they are seeking their dual certification), please do not provide an evaluation for those competencies

General Competencies: Click here to expand

Please provide evaluation on all of the Core Competencies. Click the statement you are evaluating the peer worker on, and then “meets”, “making progress”, or “does not meet”.

Shares their personal experience in a strategic, compassionate and responsive manner and comfortably discloses status
meets making progress does not meet
Demonstrates a commitment to personal self-management of health conditions and treatment regimens
meets making progress does not meet
Addresses health literacy needs of clients to ensure client understanding of messages delivered
meets making progress does not meet
Communicates using a person-centered approach such as active listening, stages of change, motivational interviewing and/or harm reduction counseling
meets making progress does not meet
Upholds agency confidentiality policies and procedures
meets making progress does not meet
Recognizes own vulnerabilities and emotional responses to work-related matters and identifies strategies for managing the situation, including asking for help from supervisor(s) and/or other available supports
meets making progress does not meet
Recognizes the limits of their knowledge and seeks assistance from staff when needed
meets making progress does not meet
Seeks opportunities to increase knowledge and skills for peer support
meets making progress does not meet
Employs self-care strategies to wellness and prevent “burn-out”
meets making progress does not meet
Demonstrates effective oral, written and non-verbal communication skills appropriate for the work setting
meets making progress does not meet
Develops awareness of and manages own personal biases and triggers when dealing with participant, as required for their specific worksite
meets making progress does not meet
Relates to clients via their shared lived experience, despite the differences that may exist between them
meets making progress does not meet

Specialized Competencies - HCV Track: Click here to expand

Specialized Competencies - HR Track: Click here to expand

Specialized Competencies - HIV Track: Click here to expand

Specialized Competencies - PREP Track: Click here to expand

Specialized Competencies - Criminal Justice Track: Click here to expand

When you have provide all requested information, click “Complete” to convert the online form to a print-friendly format. (Be advised, the screen’s appearance will change, but the data you provided will remain). Print the form.

Peer Workers should be given the opportunity to provide feedback on the evaluation they have received. Please review the printed form with the peer worker and allow them to comment before you both sign it. The peer worker will need to scan and upload his/her completed evaluation to his/her online application on https://www.hivtrainingny.org/Home/PeerCertification

Once you are complete, click here, and then right click to print a printer-friendly version of the evaluation.

Applicant Acknowledgement of Receipt of Evaluation

I acknowledge receipt of this evaluation. I have been provided an opportunity to add my comments to this evaluation. Any comments are written in the space below.

Peer Worker Signature___________________________________________________

Supervisor Signature:	_____________________________	Date:	______

New York State Certified Peer Worker Supervisor Practicum/Work Experience Evaluation Form

General Competencies: Click here to expand

Specialized Competencies - HCV Track: Click here to expand

HCV Testing

For clients with a positive/reactive HCV test result

For clients with a negative/nonreactive HCV test result

Engagement, Linkage and Retention to Care

Hepatitis C Treatment

Patient Navigation

Client Self-Management

Harm Reduction, Syringe Access and Health Promotion

Support Groups

Supportive Services

Case Conferencing

Facilitating client involvement in continuous quality improvement (QI) efforts

Health Coverage

Documentation and Record-Keeping

Specialized Competencies - HR Track: Click here to expand

Harm Reduction Competencies

Promoting access to sterile injection equipment and supplies

Safer injecting practices

Promoting safe syringe disposal

Safe Handling of syringes

Preventing Opioid Overdose

Making Service Referrals

Participant Self-Management

Facilitating involvement in continuous quality improvement (QI) efforts

Documentation and Record-Keeping

Specialized Competencies - HIV Track: Click here to expand

HIV Testing

For clients with a preliminary positive rapid HIV test result

For clients with a confirmed positive HIV test result

For clients with a negative or indeterminate test result

Engagement, Linkage and Retention to Care

Anti-retroviral Therapy (ART) Initiation and Treatment Adherence

Patient Navigation

Client Self-Management

Harm Reduction, Syringe Access and Health Promotion

Support Groups

Supportive Services

Case Conferencing

Facilitating Client Involvement in Continuous Quality Improvement Efforts

Health Coverage

Documentation and Record-Keeping

Specialized Competencies - PREP Track: Click here to expand

Employs a non-judgmental, sex positive approach

Explaining PrEP

Navigating PrEP Financial Assistance Programs

Client Self-Management and Adherence

Explaining PEP

Sharing Harm Reduction Strategies

Addressing Trauma, Sexual Assault and Intimate partner violence

Addressing the Interplay of Sexuality and Substance Use

Explaining a Status Neutral Approach to HIV including, HIV Treatment as Prevention (TasP) and Undetectable =Untransmitable (U=U)

Case Conferencing

Documentation and Record-Keeping

Specialized Competencies - Criminal Justice Track: Click here to expand

Understands basic information about the Criminal Justice System

Community Re-entry Competencies

Harm Reduction Competencies

Preventing Opioid Overdose

Gender and Sexual Health

Supporting Health

Patient Navigation

Client Self-Management

Support Groups

Supportive Services

Case Conferencing

Facilitating involvement in continuous quality improvement (QI) efforts

Documentation and Record-Keeping

New York State Certified Peer Worker
Supervisor Practicum/Work Experience Evaluation Form