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Feedback (Receiver) Assessment Form

Student Name:
Feedback Giver Questions Rubric

When receiving feedback, to what extent did this A Good A Great


N/A None A little Somewhat
team member… Amount Deal

1. …listen carefully and respectfully? (positive)


2. …ask for clarification (when necessary)?
(positive)
3. …engage in thoughtful discussion regarding
solutions? (positive)
4. …exhibit self-awareness during the
situation? (positive)
5. …express gratitude for the other person’s
efforts to help them improve? (positive)
6. …Become overly defensive or emotional?
(negative)
7. …Use body language that suggested s/he was
not open to feedback? (negative)

Overall Perceptions
11. Overall, how would you evaluate the Not bad, but
way in which this team member received definitely Decent/ Really
Poor Outstanding
feedback? room for Average Strong
improvement.

Use the following pages to make note of key examples and to offer your suggestions for how this team member
might improve when receiving feedback in the future:
Feedback notes, cont’d…

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