Canadian OTA and/or PTA Student Fieldwork

Evaluation Form

Student’s Name: Ashleigh Cole

Placement ☐ Field Placement I ☒ Field Placement II

☐ Block Placement
Durham College Advisor
Name:
Clinical Supervisor’s Name Rahim Virji, O.T. Reg., (Ont.)
Clinical Supervisor’s
OT
Designation:
Village of Taunton Mills LTC and RH
Name of Facility
☒OTA
Discipline Focused on ☐PTA
During Placement: ☐OTA & PTA
Ratio OTA:PTA Click here to enter text.%
☐Acute care ☐Rehabilitation ☒Long Term Care
Facility Setting:
☐Day Hospital ☐Community ☐Out-patient clinic
☐Other:
Client Population ☐Paediatric ☐Adult ☒Geriatric ☐Other:
Check all that apply
☒MSK ☐Mental Health ☐Respiratory ☐Endocrine
Client Category
☒Neuro ☐Cardiac ☐Oncology ☐Transplant
Check all that apply
☒Multiple Systems ☐Other:

Submission of the Preceptor’s evaluation form to the Program Coordinator

 Via mail to:
Teresa Avvampato, OTA/PTA Program
School of Health and Community Services
Durham College
2000 Simcoe Street N
Oshawa, On, Canada, L1H 7K4

 Via email or fax with original form followed in mail.

 Via your assigned advisor

*** Please note for tracking hours, please sign the Attendance Form (pg. 11-12) and students will
take an electronic copy and submit this to demonstrate completion of the required hours – this
must be received within 24 hours following placement completion ***

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 Expectations for Student Performance
Clinical Supervisors are to progress the student from basic practice principles and
techniques to “entry level” within the area of practice. Please note that students may be
in the second year of their training, however, they may be experiencing a particular area of
practice (eg. acute medicine) for the first time on this placement. This student’s
development will therefore represent a basics-to-entry-level progression pattern despite
their status within the program overall.

Competencies describe the general abilities required to accomplish the main tasks, functions and/or roles of
an OTA and/or PTA. They focus on the skills, knowledge and attitudes required to deliver optimal client-
centered care in a safe, ethical and effective manner. For each competency, there are examples of
performance indicators to help guide your evaluation. There may be other performance indicators specific to
your clinical setting that you will consider in your rating.

To complete the form:

 For each competency identified, evaluate the student’s competency using the 5-point rating scale below.
 When rating their performance, the scores should reflect the level of their competency at the time of
evaluation, at midterm and final weeks. Provide comments to support rating selected and any
recommendations for areas, student may need to work on to improve or consolidate their learning.
 Comment(s) on the student’s performance provide valuable insight and feedback on how the student is
performing at this placement. Providing comments at midterm and final evaluations will assist the student
to improve their performance.
 Midterm and Final Summary Pages are completed at midterm and end of placement.
 Signatures of the clinical supervisor(s) and student must be provided on the form.
 If the clinical supervisor is an Assistant, the therapist assigning the duties to their Assistant
must also sign the form.

Rating Scale:
Competency Rating Scale & Descriptors
Student can consistently and reliably perform competency/skill
5 Independent independently at entry-level1 practice, following clinical supervisor’s
instruction, within this specific practice setting.
Student can perform the competency/skill with occasional (minimal)
Approaching
4 guidance, support, and/or direction from Clinical Supervisor (OTA/OT
independence
and/or PTA/PT)
Student demonstrates significant gains in the acquisition of skills and
Acquiring
3 knowledge related to the role. Student can perform competency/skill
independence
with regular (moderate) guidance, support, and/or direction
Student demonstrates a basic understanding of skills and knowledge
Emerging
2 related to the role. Student can perform competency/skill with
independence
continuous (maximum) guidance, support, and/or direction
Student demonstrates poor /a lack of understanding of skills and
1 Unsatisfactory knowledge related to the role. Student unable to perform
competency/skill without direct cueing.

Discussing the evaluation

 The clinical supervisor should meet with the student to discuss the contents of the evaluation and
areas of strength and areas requiring improvement.
 Students should contribute to this discussion by completing this form as a self-evaluation prior to
meeting with the clinical supervisor.
 This provides an opportunity for student to have an understanding of how they are performing and
areas to work on to develop their competencies as an OTA & PTA.

1 An entry level OTA and PTA is defined as clinician who is a recent graduate of an OTA and/or PTA program and who is in the early
stages of their career (example, within the first 3 - 6 months of practice).
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Rating Scale: 5: Independent, 4: Approaching independence, 3: Acquiring independence,
2: Emerging independence, 1: Unsatisfactory

Professionalism & Accountability

3
Midterm

4
Final

Mid-term comments

Good understanding of role in placement. Excellent support and assistance seeking.

Final comments
Ashleigh has been excellent in her level of maturity and understanding of her role.
3
Midterm
Takes responsibility for service components as assigned
Examples of Performance Indicators: Prioritizes assigned duties and resources 4
appropriately. Demonstrates effective time management skills. Final

Mid-term Comments
Very good.

Final comments

Excellent! Very little supervision required r/t time management skills.

3
Midterm
Demonstrates professional behaviors
Examples of Performance Indicators: Exhibits respect, initiative and enthusiasm.
Follows workplace expectations (e.g. policies and procedures, hours of work, 4
Final
attire, hygiene, use of technology). Assumes responsibility for own actions.
Maintains appropriate boundaries in therapeutic and professional relationships.
Mid-term Comments

No issues apparent thus far in placement. Good acceptance of responsibilities for her own actions. Projects
confidence and excellent professionalism.

Final comments

Further excellence observed since mid-term. Meets expectations of professional behaviors very well.

Professionalism & Accountability

3
Midterm
Engages in self-reflection
Examples of Performance Indicators: Identifies strengths and areas for 4.5
improvement. Accepts constructive feedback and integrates recommendations Final
into practice. Develops and implements learning strategies using appropriate
resources.
Rating Scale: 5: Independent, 4: Approaching independence, 3: Acquiring independence,
2: Emerging independence, 1: Unsatisfactory

Mid-term comments

Good response to preceptor feedback about understanding how important self-reflection is and how it can effect
the success of one’s practice.

Final comments

Ashleigh has demonstrated a great improvement in accepting constructive feedback and improving her desire to
bring new ideas to preceptor after reflecting more since mid-term. She has truly excelled in this area.

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Rating Scale: 5: Independent, 4: Approaching independence, 3: Acquiring independence,
2: Emerging independence, 1: Unsatisfactory

Communication & Collaboration

3
Midterm
Communicates in a Professional Manner
Examples of Performance Indicators: Establishes rapport. Adapts
communication strategies to reduce communication barriers and support 4
diversity (e.g. considering education, culture, age and gender). Promotes optimal Final
client and team performance (e.g. cueing, providing feedback with dignity and
empathy, listening, guiding)
Mid-term comments
Excellent communication skills amongst peers, staff, and residents. Keep it up.

Final comments

Continued excellence observed in Ashleigh’s ability to communicate throughout placement with clarity and
respect. Great job.

Uses communication skills effectively 3

Midterm
Examples of Performance Indicators: Clearly and accurately exchanges verbal
information (e.g. speaks with a clear, audible voice, confirms understanding,
actively listens). Recognizes, utilizes and responds to non-verbal cues. Uses
language and terminology suited to the interaction. Uses written communication 4
Final
in a timely and accurate manner according to workplace expectations (e.g.
documenting in clients’ charts, caseload log, taking messages, emails, flow
sheets).
Mid-term comments

SOAP note writing needs minimal re-writing based on feedback from preceptor.

Final comments

Significant improvement noted in Ashleigh’s SOAP note writing. Very few (if any, at times) corrections are
required by final evaluation. Great work Ashleigh!

Collaborates with Inter-professional Team 3

Midterm
Examples of Performance Indicators: Recognizes roles of team members.
Participates actively as a team member to optimize client care and provide 4
continuity in service delivery. Consults with/reports to the appropriate team Final
member. Identifies and manages conflict.

Mid-term comments
Good collaboration with others demonstrated. Coaching has been provided for improvement in this area.

Final comments
Ashleigh has demonstrated improvement and has shown that she can work well in a collaborative team setting numerous
times since mid-term. Very well done!

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Rating Scale: 5: Independent, 4: Approaching independence, 3: Acquiring independence,
2: Emerging independence, 1: Unsatisfactory

Treatment Implementation
Competency: 3
Midterm
Performs assigned therapeutic interventions (direct patient care)
Examples of Performance Indicators: Applies safe practices in the workplace
(e.g. follows precautions and contraindications, proper body mechanics,
equipment safety). Explains therapeutic benefits of treatment specific to client. 4
Participates in client education. Implements therapeutic intervention using a Final
client-centred approach. Follows the timing, frequency, location and duration of
interventions. Monitors and addresses client’s response to treatment. Contributes
to treatment planning (e.g. data collection, treatment progressions and
modifications). Brings session to a close.
Mid-term comments

Responding well to preceptor guidance. Ashleigh is performing very well when delivering care to residents.

Final comments

Ashleigh has demonstrated noticeable improvement in her patient care since mid-term. She follows OT
treatment plan effectively and with greater confidence. She is able to discern the resident’s condition and how it
may effect that days treatment efficacy and outcome. Excellent work Ashleigh.

Competency: 3
Midterm
Performs assigned therapeutic interventions (indirect patient care)
Examples of Performance Indicators: Appropriate set up, clean up and follow up
as per client needs and facility protocol. Prepares for intervention (e.g. chart
review, understands therapeutic goals and treatment plan, gathers equipment, 4
Final
environmental scan, follows precautions and contraindications).

Mid-term comments

Good.

Final comments
Very good!

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Rating Scale: 5: Independent, 4: Approaching independence, 3: Acquiring independence,
2: Emerging independence, 1: Unsatisfactory

Treatment Implementation
Demonstrates critical thinking Midterm 3
Examples of Performance Indicators: Integrates knowledge (e.g. anatomy,
physiology, pathology) into practice. Recognizes need for, and seeks assistance
or clarification when appropriate. Responds appropriately to ethical and moral
dilemmas. Demonstrates effective problem-solving (e.g. identifies problems, 4.5
Final
determines possible options, recognizes risks, implement solution, reflect and
revise). Analyzes and interprets information accurately (e.g. chart review)

Mid-term comments

Ashleigh has demonstrated excellent critical thinking skills since the beginning of placement and has followed
preceptor guidance very well. Keep it up.

Final comments

Ashleigh shown improvement with thinking critically and analyzing information as it pertains to OTA work. Great
work.

Protects the client from harm 3

Midterm
Examples of Performance Indicators: Obtains client’s informed consent prior to
performing assigned tasks. Maintains client/family and organizational
confidentiality. Takes precautions to ensure the client’s safety and dignity (e.g. 4
Final
safe use of equipment, infection control, correct handling techniques, draping,
privacy)

Mid-term Comments

Good.

Final comments

Improved.

Organization of Service Delivery

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Rating Scale: 5: Independent, 4: Approaching independence, 3: Acquiring independence,
2: Emerging independence, 1: Unsatisfactory

Competency: 3
Midterm
Performs non-clinical duties
Examples of Performance Indicators: Organizes and maintains equipment,
supplies, and written resources. Completes administrative tasks (e.g. workload 4
Final
measurements, scheduling, quality improvement initiatives, inventory).
Participates in education of team members, peers, and other learners as
assigned.
Mid-term comments

Good.

Final comments

Very good!

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Midterm Summary
Performance at Midterm:
Exemplary Satisfactory Unsatisfactory (explain below)

General Comments:

Very good work ethic, professionalism, and awareness of role.

Strengths:
- Well organized.
- Good work ethic
- Attention to detail
- Good maturity

- Asks relevant questions

- Accepts feedback well from preceptor.

Areas for growth:

The midterm evaluation was reviewed with the student

Clinical Supervisor(s): Date

X
Rahim Virji, O.T. Reg. (Ont.)
Placement Preceptor
Rahim Virji_____________ _________
_____________ Oct. 23, 2017______
Print Name / Designation Signature

The midterm evaluation was reviewed with the clinical supervisor

______________________ ______________________ _____________________

Student Print Name Signature

Student was well prepared for this placement. Yes No

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If no, please indicate areas of insufficiency.

Comments:

Final Summary of Evaluation of Clinical Competencies

To be completed at the end of the placement only.

General Comments:

Strengths:
- Willingness to learn.
- Good personality
- Continues to ask questions and learns well from them
- Good insight into her role and how it helps residents.

Areas for growth:

- Continue working on critical thinking skills

Attendance: No. of days No. of days Total hours completed at placement:

absent: 0 late: 0 ____200________

Profession allocation of OTA:PTA

_100_____%:______%
Reason for absence:

Overall Performance on this Placement:

Exemplary Satisfactory Unsatisfactory (explanation required)

Clinical Supervisor(s): Date

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 X
Rahim Virji, O.T. Reg., (Ont.)
Placement Preceptor
Rahim Virji, O.T. Preceptor ____________
__________ December 6, 2017
Print Name / Designation Signature

______________________ ______________________ _____________________

Print Name / Designation Signature

Supervising OT or PT
______________________ ______________________ _____________________
Print Name / Designation Signature

______________________ ______________________ _____________________

Print Name / Designation Signature

Student signature verifies that the evaluation was reviewed with the evaluator(s)

______________________ ______________________ _____________________

Print Name Signature

Page ______ of _______

Fieldwork Attendance Form

FACILITY NAME & AREA OF PRACTICE:____________________________________________________________

STUDENT’S NAME: _____ DATES OF PLACEMENT:_____________________

Date OTA hours PTA hours Preceptor Signature & Comments

completed completed
each day each day

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Instructions for Preceptor: The student is responsible for maintaining this record. In order to verify that students
have attended the required hours, please sign in the appropriate space below each time the student attends
placement. Students are required to submit this electronically to demonstrate completion of placement hours.

Total OTA Hours on Placement: ___________ Total PTA Hours on Placement: ___________

Preceptor signature: _______________________________ Date: _________________________________

Student signature: _________________________________ Date: _________________________________

Page ______ of ______

Fieldwork Attendance Form

FACILITY NAME & AREA OF PRACTICE:____________________________________________________________

STUDENT’S NAME: _____ DATES OF PLACEMENT:_____________________

Date OTA hours PTA hours Preceptor Signature & Comments

completed completed
each day each day

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Instructions for Preceptor: The student is responsible for maintaining this record. In order to verify that students
have attended the required hours, could please sign in the appropriate space below each time the student attends
placement. Students are required to submit this electronically to demonstrate completion of placement hours.

Total OTA Hours on Placement: ___________ Total PTA Hours on Placement: ___________

Preceptor signature: _______________________________ Date: _________________________________

Student signature: _________________________________ Date: _________________________________

Optional Feedback Form

Durham College is committed to developing OTA/PTAs that are responsive to our community’s
needs. We welcome your feedback and strive to provide a positive experience for our
community partners, clients, preceptors and students.

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 1) Please identify any areas of strength OR areas requiring further development with
regard to the preparedness of our students (knowledge/skills):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

2) Please provide feedback regarding the placement process and your overall experience
as a preceptor in the OTA/PTA program:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

3) Please any additional feedback or recommendations you would like to share:

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

With our kindest thanks for sharing your valuable time and expertise with our students. We
hope that this has been a positive experience and look forward to working with you in future.

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