The following is suggested by Anne Schjoldager as a table for students to chart their performances while interpreting in simultaneous mode. The first table contains examples, the second is could be used a students as a log book over a number of weeks allowing the identification for example of recurring problems.
The full text can be found in,
Schjoldager, Anne, Assessment of Simultaneous interpreting. In Dollerup and Appel, (editors) Teaching Translation and Interpreting 3. 1996 Benjamins.
Note also the fact that the questions underline the positive elements of the performance (in that most answers will be “NO”).