The Ohio State University School of Health & Rehabilitation

Occupational Therapy
Evaluator: Joanie Smith - FW Educator Subject: Shannon Joyce - Level 1 Student

Activity: Level One FW 6189 Mental Health Site: Kettering Health Network

Evaluation Type: Fieldwork Level I Evaluation Completion Date: 03/16/2018

Request Date: 03/13/2018

Period: Level 1 Mental Health 2018 Spring Break Dates of Activity: 03/12/2018 To 03/16/2018

Subject Participation Dates: 03/12/2018 To 03/16/2018

STUDENT LEVEL I EVALUATION OF PROFESSIONALISM

Evaluation form developed from: Napier, B. (2011). Occupational therapy fieldwork survival guide: A student planner, 2nd ed.
Bethesda, MD: AOTA Press.

 (Question 1 of 5  - Mandatory ) 

STUDENT NAME Shannon Joyce

Number of Hours Completed: 40

FACILITY SUPERVISOR- NAME and CREDENTIALS/TITLE: Joanie Smith MS OTR/L

Years of Experience: 38

Supervisor Email Address (for CEU certificate) Joaniebaloney17@sbcglobal.net

FACILITY NAME: Kettering Behavioral Medical Center

 (Question 2 of 5  - Mandatory ) 
Please check the box that indicates the student's level of performance
N "Needs Improvement" = Opportunities for improvement and work is occasionally unacceptable
M "Meets Standards" = Carries out required tasks and activities. Solid performance.
N M E
E "Exceeds Standards" = Carries out tasks and activities that often surpass requirements. Performance is the best
that can be expected. This should be used only for strengths.

**Comments required for all scored as an N**

1. Dependability (consider ability to arrive on time, follows through on assignments, notifies supervisor of schedule X
issues)
2. Competence (consider ability to be prepared, asks for help when needed, ensures safety, comfort, and rights of X
clients)
3. Communication (consider ability to use appropriate level of language, positive non-verbal communication and X
tone, maintain boundaries, responds well to and uses feedback)
4. Integrity (consider ability to respect and maintain confidentiality, act with honesty, accept responsibility for self, X
value and care for the equipment and resources of the facility)
5. Cooperation and Teamwork (consider ability to make positive contributions to the team process, accept group X
decisions, complete own share of the work, give credit to those who deserve it)
6. Empathy/Compassion (consider ability to be non-judgmental and respectful, culturally sensitive, and listen X
actively)
7. Initiative/Self-directed learning (consider ability to be motivated, to seek out opportunities to acquire information X
from a variety of sources, and accept and apply feedback)
8. Professional Appearance (consider appropriate clothing, good personal hygiene, discrete body adornment, X
appropriate body posture and facial expressions that send reassuring messages to clients)
9. Flexibility/Adaptability (consider ability to make change to treatment plan, react to client, make change in self X
after feedback)
10. Assessment Activities (consider choosing correct assessment, adheres to standardization, correctly X
documents results)
11. Intervention Activities (consider matching intervention to assessment and client needs, executes activity
X
without assistance)
Overall Score: Please rate your overall impression of this student's performance X
*In order to pass, needs to obtain an M in this category*

Comments  (Question 3 of 5 ) 

Shannon was a delight to have in our facility for her level one experience. We highly think she will make a great future Occupational
Therapist!

Supervisor Electronic Signature:  (Question 4 of 5  - Mandatory ) 

Please enter your name in the text box below-

Joanie Smith MS OTR/L

Date:  (Question 5 of 5  - Mandatory ) 
03/16/2018