Performance Checklist
Results: Student: Examiner Date:

 

Client Intake Practical Exam

A. Interviewing The Client

COMPETENCY QUESTION STANDARDS

YES

NO
  1. Greeted and welcomed the client?
 - say hello or welcome

- address the client by name (clarify how to address the client)

-welcome anyone accompanying the client

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  • Established a comfortable and private physical space to hold the interview?
 -maximizes privacy

-sat facing client directly or sat besides client

positioned self at the same level as client

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  • Introduced self to the client?
 -say first name

-say last name

-say title

-say how to address by name

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  • Established rapport with the client?
    •
-communicated warmth and concern, e.g., "How are you today?"

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  • Stated the purpose of the interview?
 -say why the interview is taking place

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  • Explained what to expect during the interview?
 -how long the interview will take

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  • Explained confidentiality policy?
 -stated the agency’s confidentiality policy

-say who has access to the file.

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  • Explained the agency’s immigration rights policy?
-say the agency’s policy regarding the INS with realistic reassurances.

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Comments:

 

 

 

Performance Checklist

Client Intake Practical Exam

A. Interviewing The Client

COMPETENCY QUESTION STANDARDS

YES

NO
  1. Explained how the agency uses the client’s social security number and identification number?
 -said how their ID number will be used.

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  • Communicated in an easy to understand manner?
 -did not use jargon

-did not use acronyms

-spoke distinctly at a comfortable pace.

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  • Monitored the client’s understanding of the interview?
 -observed body language for signs of understanding, e.g., frowns, nods, etc.

-asked, "Do you have any questions?"

-maintained eye contact

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  • Took notes in a nonintrusive manner?
 -maintained eye contact while notetaking

-maintained attention during interview

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  • Explained to the client what to expect after the interview?
-said when the next contact will take place

-told the client when and how services will begin

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Comments:

Performance Checklist

Client Intake Practical Exam

B. Orienting The Client To The Program/Agency

COMPETENCY CRITERIA STANDARDS

YES

NO
  1. Explained the purpose of the program/agency?
    2.
-explain mission statement of the agency.

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  • Explained agency services?
    •
-provided a list of agency services

-told what they will need to access services: identification, money, transportation.

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  • Provided agency phone numbers and discussed with the client how to contact agency?
    •
-discuss the contact information with the client

-told phone hours

-told who to contact.

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  • Explained who will be involved in providing services?
    •
-describe their roles clearly

-no jargon or acronyms

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  • Explained to the client what to do in case of an emergency?
    •
-who to call

-where to go

-what to bring.

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  • Monitored the client’s understanding of the interview.
-observed body language for signs of understanding, e.g., frowns, nods, etc.

-asked, "Do you have any questions?’

-maintained eye contact

¨

¨

Comments:

Performance Checklist

Health Advising

A. Health Advising

COMPETENCY QUESTION STANDARDS YES NO
  1. Identified client health concern/ problem?
    2.
-reflected back to the client the stated health concern

-actively listened for deeper issues, e.g., embarrassment

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  • Discussed health concern with the client?
 -discuss accurate health information

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  • Provided informational pamphlets/brochures?
    •
-give client appropriate brochures/pamphlets

-discussed information with client

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  • Identified myths expressed by the client?
    •
-accurately identified myths

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  • Discussed myths and facts a bout health concern?
    •
-provided accurate information

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  • Answered client questions?
    •
-responded in a nonjudgmental manner

-gave accurate information

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  • Used plain language when communicating with client?
    •
-did not use jargon

-did not use acronyms

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  • Used active listening techniques?
    •
-reflected back to the client what was expressed

-made eye contact

-used appropriate body language

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  • Used "I messages" to communicate vs. blame and judgment?
 

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Comments:

 

 

 

 

 

 

Performance Checklist

Care Coordination

A. Referral And Information/Tracking And Follow Up

COMPETENCY QUESTION STANDARDS YES NO
  1. Explained the purpose of the referral given?
    2.
-described the referral.

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  • Explained how the referral will benefit the client?
    •
-explained how the referral will improve the current situation

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  • Provided detailed information about the referral?
    •
-said who to contact

-said what to bring

-said agency hours

-told tips about how to best access services

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  • Identified possible barriers to accessing the referral?
 -informed client of cost

-transportation

-immigration status, drug rehabilitation status, criminal record

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  • Used referral resource guide to look up detailed information about the referral?
 -used the index and table of contents to look up referral agencies

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  • Scheduled a follow up appointment with the client?
-arranged an appointment with the client

-wrote the date and time of the appointment on a card for the client

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Comments:

 

Performance Checklist

The following should be answered by the actor:

1) Did the student (playing a Community Health Worker) make you feel welcomed?

 

 

 

 

2) Would you come back to this clinic? Would you come back to this Community Health Worker?

 

 

 

 

3) Your comments:

 

 

 

 

 

 

 

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