Field Supervisor’s Documentation of Concerns/Issues
(Refer to the Field Manual under probation and termination of a student from field for additional information)
Student Name: ________________________________________ Date:___________________
Field Agency:__________________________________________________________________________
Field Supervisor: ______________________________________________________________________
Task Supervisor: ______________________________________________________________________
Field Director: _______________________________________________________________________
1. Please identify area of concern/issue with student’s performance.
2. Identify the behavior expected from the student in concrete terms which is to replace the
3. Identify, if applicable the time frame in which change is to occur.
4. Identify consequences to the student if the desired behavior/change does not occur.
5. Provide documentation, if applicable of any previous discussions with this student which have
occurred about this issue (attach any documentation such as weekly supervision log/note).
6. Additional Comments
_____________________________ _______________________________________________
Student Signature Date Field and or Task Supervisor Signature Date
Please submit the original signed form to the Field Director.
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