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12/8/21, 6:07 PM Mail - KATELYN HENNIS - Outlook
AOTA - Fieldwork Performance Evaluation Final OTS

Jeanette Koski <noreply+0e2a36de643c86b4@formstack.com>
Thu 9/9/2021 3:00 PM
To: KATELYN HENNIS <u1250388@utah.edu>
Formstack Submission For: AOTA - Fieldwork Performance

Evaluation Final OTS
Submitted at 07/29/21 4:52 PM
STUDENT OR FIELDWORK FIELDWORK EDUCATOR
EDUCATOR:
STUDENT NAME: Katelyn Hennis
STUDENT EMAIL: u1250388@utah.edu
FIELDWORK EDUCATOR Ben Ostler
NAME:
FIELDWORK EDUCATOR MOTR/L, CSRS
CREDENTIALS:
FIELDWORK EDUCATOR'S ben.ostler@hsc.utah.edu
EMAIL:
COLLEGE OR University of Utah
UNIVERSITY:
ARE THERE ADDITIONAL
FIELDWORK
EDUCATOR(S) WORKING
WITH THIS STUDENT?:
Please enter additional
Fieldwork Educator(s)
Name, Credentials, Email
and Number of Weeks:
TODAY'S DATE: Jul 29, 2021
https://outlook.office.com/mail/id/AAQkADQ1N2E2NzU5LTUyYmEtNDIwMC1hNGEzLWY1YjdlOGJiM2EzMwAQAGiQhL65IwpAuaVqueKb3Xw%3D 1/21
TYPE OF FIELDWORK: Level II Fieldwork

NAME OF Craig H Neilsen Rehabilitation Hospital
ORGANIZATION/FACILITY:
CITY: Salt Lake City
STATE: Utah
ORDER OF PLACEMENT: 1
OUT OF: 2
FROM: May 10, 2021
TO: Jul 29, 2021
TOTAL NUMBER OF 12
WEEKS:
1. Adheres to the
American Occupational
Therapy Association’s
Code of Ethics and all
federal, state, and facility 3
regulations. (Examples:
Medicare, Medicaid, client
privacy, social media,
human subject research)
(Final):
1. Adheres to the
American Occupational
Therapy Association’s
Code of Ethics and all
federal, state, and facility 3
regulations. (Examples:
Medicare, Medicaid, client
privacy, social media,
human subject research)
(Mid-term):
Question 1 Comments:
2. Adheres to safety 3
regulations and
reports/documents
incidents appropriately.
(Examples: fire safety,
OSHA regulations, body

substance precautions,
emergency procedures)
(Final):
2. Adheres to safety
regulations and
reports/documents
incidents appropriately.
(Examples: fire safety, 2
OSHA regulations, body
substance precautions,
emergency procedures)
(Mid-term):
3. Ensures the safety of
self and others during all
fieldwork related
activities by anticipating
potentially unsafe
situations and taking
steps to prevent
accidents. (Examples: 3
body mechanics, medical
safety, equipment safety,
client specific
precautions,
contraindications,
community safety)
(Final):
3. Ensures the safety of
self and others during all
fieldwork related
activities by anticipating
potentially unsafe
situations and taking
steps to prevent
accidents. (Examples: 2
body mechanics, medical
safety, equipment safety,
client specific
precautions,
contraindications,
community safety) (Mid-
term):
I - Fundamentals of Katelyn has improved each week with
Practice Comments: patient safety, body mechanics, and had

no issues with precautions and
contraindications.
4. Articulates the values,
beliefs, and distinct
perspective of the
occupational therapy
profession to clients and
other relevant parties 3
clearly, confidently, and
accurately. (Examples:
families, caregivers,
colleagues, service
providers, administration,
the public) (Final):
4. Articulates the values,
beliefs, and distinct
perspective of the
profession to clients and
other relevant parties 2
clearly, confidently, and
colleagues, service
the public) (Mid-term):
5. Articulates the value of
occupation as a method
and desired outcome of
occupational therapy to
clients and other relevant
parties clearly, 3
confidently, and
colleagues, service
5. Articulates the value of 2
occupation as a method
and desired outcome of
occupational therapy to
clients and other relevant
parties clearly,
confidently, and
colleagues, service
6. Articulates the role of
practitioners to clients
and other relevant parties
clearly, confidently, and 3
colleagues, service
6. Articulates the role of
practitioners to clients
and other relevant parties
clearly, confidently, and 2
colleagues, service
II - Basic Tenets of Katelyn is able to explain accurately, her
Occupational Therapy role as an OT to staff, caregivers, and
Comments: patients.
7. Articulates a clear and
logical rationale for the
evaluation process based
on client information, 3
contexts, theories,
frames of reference,
and/or practice models.
(Final):
7. Articulates a clear and 2
evaluation process based
on client information,
contexts, theories,
frames of reference,
and/or practice models.

(Mid-term):
8. Obtains sufficient and
necessary information
from relevant sources
throughout the evaluation 3
process. (Examples:
record or chart review,
client, family, caregivers,
service providers) (Final):
8. Obtains sufficient and
necessary information
from relevant sources
throughout the evaluation
process. (Examples: 2
record or chart review,
client, family, caregivers,
service providers) (Mid-
term):
9. Selects relevant
screening and
assessment tools based
on various factors.
(Examples: client
priorities, needs, and
concerns about 3
occupational
performance and
participation, theoretical
support, evidence,
practice context, funding
sources, cultural
relevance) (Final):
9. Selects relevant 2
screening and
assessment tools based
on various factors.
(Examples: client
priorities, needs, and
concerns about
occupational
performance and
participation, theoretical
support, evidence,
practice context, funding

sources, cultural
relevance) (Mid-term):
10. Determines the
client’s occupational
profile and occupational
performance through 3
interview and other
appropriate evaluation
methods. (Final):
10. Determines the
client’s occupational
profile and occupational
performance through 2
interview and other
appropriate evaluation
methods. (Mid-term):
11. Evaluates and
analyzes client factors
and contexts that support 3
or hinder occupational
performance. (Final):
11. Evaluates and
analyzes client factors
and contexts that support 2
or hinder occupational
performance. (Mid-term):
12. Administers
standardized and non-
standardized
assessments and surveys
accurately and efficiently
to ensure findings are 3
valid and reliable.
(Examples: follows
assessment protocols,
adheres to time
guidelines) (Final):
12. Administers 2
standardized and non-

standardized
assessments and surveys
accurately and efficiently
to ensure findings are
valid and reliable.
(Examples: follows
assessment protocols,
adheres to time
guidelines) (Mid-term):
13. Modifies evaluation
procedures based on
client factors and
contexts. (Examples: uses
a quiet space, breaks up 3
evaluation into smaller
parts, provides
multisensory
instructions) (Final):
13. Modifies evaluation
procedures based on
client factors and
contexts. (Examples: uses
a quiet space, breaks up 2
evaluation into smaller
parts, provides
multisensory
instructions) (Mid-term):
14. Interprets evaluation
results to determine the
client’s occupational 3
performance strengths
and challenges. (Final):
14. Interprets evaluation
results to determine the
client’s occupational 3
performance strengths
and challenges. (Mid-
term):
15. Synthesizes and 3
documents the results of

the evaluation process
clearly, accurately, and
concisely, using
systematic methods to
record the client’s
occupational
performance. (Final):
15. Synthesizes and
documents the results of
the evaluation process
clearly, accurately, and
concisely, using 3
systematic methods to
record the client’s
occupational
performance. (Mid-term):
After midterm and due to increase in
evaluations, Katelyn was able to get a
III - Screening and chance to complete multiple evaluations.
Evaluation Comments: She demonstrates the ability to get the
necessary information and do the
relevant screens/tests (MMT, SCIM,
ASIA, visual screen).
intervention process
based on the evaluation
results, contexts, 3
theories, frames of
reference, practice
models, and evidence.
(Final):
intervention process
results, contexts, 2
theories, frames of
reference, practice
models, and evidence.
(Mid-term):
17. Establishes an 3
accurate and appropriate

client-centered plan
results, contexts,
theories, frames of
reference, and/or practice
models. (Final):
17. Establishes an
accurate and appropriate
client-centered plan
based on the evaluation 2
results, contexts,
theories, frames of
reference, and/or practice
models. (Mid-term):
18. Uses evidence from
research and relevant
resources to make 3
informed intervention
decisions. (Final):
18. Uses evidence from
research and relevant
resources to make 3
informed intervention
decisions. (Mid-term):
19. Selects client-
centered and occupation-
based interventions that
motivate and challenge 3
the client to achieve
established goals that
support targeted
outcomes. (Final):
19. Selects client-
centered and occupation-
based interventions that
motivate and challenge 3
the client to achieve
established goals that
support targeted
outcomes. (Mid-term):
20. Implement client-
centered and occupation- 3
based intervention plans.
(Final):
20. Implement client-
centered and occupation- 3
based intervention plans.
(Mid-term):
21. Chooses and, if
needed, modifies
intervention approach to
achieve established goals
that support targeted 3
outcomes. (Examples:
prevention, restoration,
maintenance, promotion)
(Final):
21. Chooses and, if
needed, modifies
intervention approach to
achieve established goals
that support targeted 2
outcomes. (Examples:
prevention, restoration,
maintenance, promotion)
(Mid-term):
22. Modifies task and/or
environment to maximize
the client’s performance.
Examples: 3
upgrades/downgrades
task; arranges client’s
workspace for optimal
performance (Final):
22. Modifies task and/or 2
environment to maximize
the client’s performance.
(Examples:
upgrades/downgrades
task; arranges client’s
workspace for optimal

performance) (Mid-term):
23. Modifies the
intervention plan and
determines the need for
continuation or 3
discontinuation of
services based on the
client's status. (Final):
23. Modifies the
intervention plan and
determines the need for
continuation or 2
discontinuation of
services based on the
client's status. (Mid-
term):
24. Documents the
client's response to
services in a manner that 3
demonstrates the
effectiveness of
interventions. (Final):
24. Documents the
client's response to
services in a manner that 3
demonstrates the
effectiveness of
interventions. (Mid-term):
Katelyn improved throughout her FW the
ability to adapt, modify, and create the
"just right" challenge. She often involved
IV - Intervention important occupations with our varied
Comments: patients. She is able to brainstorm and
plan alone and with others on how to
best address these areas - from BADLS
to leisure activities.
25. Demonstrates through 3
practice or discussion the
ability to collaborate with

and assign appropriate
tasks to the occupational
therapy assistant,
aide, or others to whom
responsibilities might be
assigned, while remaining
responsible for all aspects
of treatment. (Examples:
paraprofessionals,
nurses’ aides, volunteers)
(Final):
25. Demonstrates through
practice or discussion the
ability to collaborate with
and assign appropriate
tasks to the occupational
therapy assistant,
aide, or others to whom 2
responsibilities might be
assigned, while remaining
responsible for all aspects
of treatment. (Examples:
paraprofessionals,
nurses’ aides, volunteers)
(Mid-term):
26. Demonstrates
through practice or
discussion an
understanding of costs
and funding systems 3
related to occupational
therapy services, such as
federal, state, third party,
and private payers.
(Final):
26. Demonstrates 2
through practice or
discussion an
understanding of costs
and funding systems
related to occupational
therapy services, such as
federal, state, third party,
and private payers. (Mid-
term):
27. Demonstrates
knowledge about the
organization. (Examples:
mission and vision, 3
accreditation status,
licensing, specialty
certifications) (Final):
27. Demonstrates
knowledge about the
organization. (Examples:
mission and vision, 2
accreditation status,
licensing, specialty
certifications) (Mid-
term):
28. Meets productivity
standards or volume of
work expected of 4
students. (Final):
28. Meets productivity
standards or volume of
work expected of 4
students. (Mid-term):
Katelyn has demonstrated consistently
V - Management of her ability to meet the productivity
Occupational Therapy standards and volume of work. She has
Services Comments: met with the OT manager and used (or
explained how she would use therapy
aides in this setting).
29. Communicates clearly
and effectively, both
verbally and nonverbally.
(Examples: clients, 3
colleagues, service
29. Communicates clearly

and effectively, both
verbally and nonverbally.
(Examples: clients, 2
colleagues, service
30. Produces clear and
accurate documentation.
(Examples: legibility,
spelling, punctuation, 3
grammar, adherence to
electronic health
documentation
requirements) (Final):
30. Produces clear and
accurate documentation.
(Examples: legibility,
spelling, punctuation,
grammar, adherence to 3
electronic health
documentation
requirements) (Mid-
term):
31. Collaborates with
fieldwork educator(s) to 3
maximize the learning
experience. (Final):
31. Collaborates with
fieldwork educator(s) to 3
maximize the learning
experience. (Mid-term):
32. Takes responsibility 3
for attaining professional
competence by seeking
out learning opportunities
and interactions with
fieldwork educator(s) and
others. (Final):
32. Takes responsibility

for attaining professional
competence by seeking
out learning opportunities 3
and interactions with
fieldwork educator(s) and
others. (Mid-term):
33. Responds
constructively to 3
feedback in a timely
manner. (Final):
33. Responds
constructively to 3
feedback in a timely
manner. (Mid-term):
34. Demonstrates
consistent and
acceptable work
behaviors. (Examples:
punctuality, initiative, 4
preparedness, flexibility,
dependability,
professional appearance)
(Final):
34. Demonstrates
consistent and
acceptable work
behaviors. (Examples:
punctuality, initiative, 3
preparedness, flexibility,
dependability,
professional appearance)
(Mid-term):
35. Demonstrates
effective time 4
management. (Final):
35. Demonstrates 2
effective time
management. (Mid-term):
36. Manages
relationships effectively
through therapeutic use
of self and adjusts 4
approach to meet the
needs of clients and
others. (Final):
36. Manages
relationships effectively
through therapeutic use
of self and adjusts 3
approach to meet the
needs of clients and
others. (Mid-term):
37. Demonstrates respect
for diversity factors of
others. (Examples: 3
culture, socioeconomic
status, beliefs, identity)
(Final):
37. Demonstrates respect
for diversity factors of
others. (Examples: 3
culture, socioeconomic
status, beliefs, identity)
(Mid-term):
VI - Communication and Katelyn has demonstrated an
Professional Behaviors improvement in verbal communication
Comments: with other staff and patients. She shows
an improvement with jumping in during
eval conference to report about patients
and with communicating with patients,
instead of sitting back.
Katelyn has shown throughout her FW
experience here that she is appropriate,
professional, timely, and flexible. She has
continued to develop her therapeutic use
of self and connected strongly with

patients, caregivers, and staff alike.
FINAL TOTAL: 115
Pass/Fail: Pass
Pass/Fail:
1. (Final) AOTA Code of 3
Ethics:
2. (Final) Safety 3
Regulations:
3. (Final) Safety of 3
Self/Other:
4. (Final) Articulates 3
Values....:
5. (Final) Value 3
Articulation:
6. (Final) Role 3
Articulation:
7. (Final) Articulates the 3
role:
8. (Final) Obtains 3
information:
9. (Final) Selects relevant 3
tools:
10. (Final) Determines the 3
profile:
11. (Final) Evaluates and 3
analyzes:
12. (Final) Administers 3
assessment:
13. (Final) Modifies 3
evaluation:
14. (Final) Interprets 3

eval..:
15. (Final) Synthesizes 3
and documents:
16. (Final) Articulates: 3
17. (Final) Establishes 3
plan:
18. (Final) Uses evidence: 3
19. (Final) Selects 3
interventions:
20. (Final) Implements 3
plan:
21. (Final) Chooses and 3
modifies:
22. (Final) Modifies task: 3
23. (Final) Modifies plan: 3
24. (Final) Documents: 3
25. (Final) Collaborate: 3
26. (Final) Demonstrates: 3
27. (Final) Demonstrates 3
organization:
28. (Final) Productivity: 4
29. (Final) 3
Communicates:
30. (Final) Produces clear: 3
31. (Final) Collaborates: 3
32. (Final) Responsibility: 3
33. (Final) Responds to 3
feedback:
34. (Final) Work 4

behaviors:
35. (Final) Time 4
Management:
36. (Final) Manages 4
relationships:
37. (Final) Demonstrates 3
success:
Katelyn was an exemplary student. She
has consistently demonstrated
professional behavior, working well with
other disciplines, and improving her
abilities during her FW. Katelyn has a way
to make everyone feel comfortable and
she was trusted by all. She uses her
strengths well and because of this she
will make an exceptional occupational
therapist. As she continues to gain
SUMMARY COMMENTS: experience I fully expect her confidence
to continue to grow, improve, and she
will be able to lead - if she so desires.
She has consistently shown
improvements and taken feedback well,
demonstrating to us that she wants to
give her patients the best care.
Katelyn will be missed by the medical
team, patients, and caregivers at NRH.
Her next FW setting will be extremely
lucky to have her.
Student was informed of Student was informed of this review
this review:
Fieldwork Educator View Signature
Signature:
Student Signature:
Copyright © 2021 Formstack, LLC. All rights reserved. This is a customer service email.
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12/8/21, 6:07 PM Mail - KATELYN HENNIS - Outlook

AOTA - Fieldwork Performance Evaluation Final OTS

Formstack Submission For: AOTA - Fieldwork Performance

TYPE OF FIELDWORK: Level II Fieldwork

OSHA regulations, body

Practice Comments: patient safety, body mechanics, and had

and/or practice models.

practice context, funding

standardized and non-

documents the results of

accurate and appropriate

workspace for optimal

ability to collaborate with

29. Communicates clearly

32. Takes responsibility

of self and connected strongly with

14. (Final) Interprets 3

34. (Final) Work 4

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