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

 

 

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

 

 

Introduced self to the client?

-say first name

 

-say last name

 

-say title

 

-say how to address by name

 

 

Established rapport with the client?

-communicated warmth and concern, e.g., "How are you today?"

 

 

Stated the purpose of the interview?

-say why the interview is taking place

 

 

Explained what to expect during the interview?

-how long the interview will take

 

 

Explained confidentiality policy?

-stated the agency?s confidentiality policy

 

-say who has access to the file.

 

 

Explained the agency?s immigration rights policy?

-say the agency?s policy regarding the INS with realistic reassurances.

 

 

 

Comments:

 

 

 

 

 

 

Performance Checklist

 

Client Intake Practical Exam

 

A. Interviewing The Client

COMPETENCY QUESTION

STANDARDS

YES

NO

9. Explained how the agency uses the client?s social security number and identification number?

-said how their ID number will be used.

 

 

Communicated in an easy to understand manner?

-did not use jargon

 

-did not use acronyms

 

-spoke distinctly at a comfortable pace.

 

 

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

 

 

Took notes in a nonintrusive manner?

-maintained eye contact while notetaking

 

-maintained attention during interview

 

 

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

 

 

 

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?

-explain mission statement of the agency.

 

 

Explained agency services?

-provided a list of agency services

 

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

 

 

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.

 

 

Explained who will be involved in providing services?

-describe their roles clearly

 

-no jargon or acronyms

 

 

Explained to the client what to do in case of an emergency?

-who to call

 

-where to go

 

-what to bring.

 

 

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

STANDARD

YES

NO

Identified client health concern/ problem?

-reflected back to the client the stated health concern

 

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

 

 

*  Discussed health concern with the client?

 

-discuss accurate health information

 

 

Provided informational pamphlets/brochures?

-give client appropriate brochures/pamphlets

 

-discussed information with client

 

 

*  Identified myths expressed by the client?

 

-accurately identified myths

 

 

Discussed myths and facts about health concern?

-provided accurate information

 

 

Answered client questions?

-responded in a nonjudgmental manner

 

-gave accurate information

 

 

Used plain language when communicating with client?

-did not use jargon

 

-did not use acronyms

 

 

Used active listening techniques?

-reflected back to the client what was expressed

 

-made eye contact

 

-used appropriate body language

 

 

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

 

 

 

 

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?

-described the referral.

 

 

Explained how the referral will benefit the client?

-explained how the referral will improve the current situation

 

 

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

 

 

Identified possible barriers to accessing the referral?

-informed client of cost

 

-transportation

 

-immigration status, drug rehabilitation status, criminal record

 

 

Used referral resource guide to look up detailed information about the referral?

-used the index and table of contents to look up referral agencies

 

 

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

 

 

 

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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