Canadian OTA and/or PTA Student

2022-2023 Fieldwork Evaluation Form

Alana Foshay
Student’s Name:

Placement □ Field Placement I ☐ Field Placement II

□ Block Placement
Durham College Advisor
Name:
Clinical Supervisor’s Name

Clinical Supervisor’s
Designation:

Name of Facility
☐ OTA
Discipline Focused on ☐ PTA
During Placement: ☐ OTA & PTA
Ratio OTA:PTA %
☐ 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 Coordinators

 Via email (word and PDF versions of the form are available

Please note:

1) All signatures are required on page 10 to authenticate this evaluation. Advise the program coordinator if you
require assistance with the form, submission or electronic signature(s).

2) For tracking hours please sign the Attendance Form daily (a sample of this document is located on pg. 11).
Students are responsible to log and submit final electronic copies of the attendance forms noting and totaling ALL
hours completed, signed by the preceptor to demonstrate successful completion of all placement hours – this must
be received within 24 hours following placement completion,

3) Passing grades: Field Placement 1 = score of 2 or above; Field Placement II = score of 3 or above;
Block/Consolidation Placement = score of 4 or above for each competency area

Reviewed May 2022

 Expectations for Student Performance

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.

Rating Scale:
Competency Rating Scale & Descriptors Required
Passing grades: FPI = 2 or above; FPII = 3 or above; Block = 4 or above for each competency area Grade
Student can consistently and reliably perform competency/skill Block
5 Independent independently at entry-level1 practice, following clinical supervisor’s 4 or above
instruction, within this specific practice setting.
Student can perform the competency/skill with occasional (minimal) Block
Approaching
4 guidance, support, and/or direction from Clinical Supervisor (OTA/OT 4 or above
independence
and/or PTA/PT)
Student demonstrates significant gains in the acquisition of skills and FP II
Acquiring
3 knowledge related to the role. Student can perform competency/skill 3 or above
independence
with regular (moderate) guidance, support, and/or direction
Student demonstrates a basic understanding of skills and knowledge FP I
Emerging
2 related to the role. Student can perform competency/skill with 2 or above
independence
continuous (maximum) guidance, support, and/or direction
Student demonstrates poor /a lack of understanding of skills and Unsuccessful
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 priorto
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).

Reviewed May 2022

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

Professionalism & Accountability

Midterm
Practices within scope of professional parameters and personal abilities 3
Examples of Performance Indicators: Performs within the scope of the OTA
and/or PTA role. Works within their role as a therapist assistant student and Final
within personal abilities and limitations. Seeks support / assistance 4
appropriately. Asks appropriate questions. Follows supervision and
communication guidelines.
Midterm 3
Takes responsibility for service components as assigned
Examples of Performance Indicators: Prioritizes assigned duties and resources
Final 4
appropriately. Demonstrates effective time management skills.

Midterm
Demonstrates professional behaviors 4
Examples of Performance Indicators: Exhibits respect, initiative and enthusiasm.
Follows workplace expectations (e.g. policies and procedures, hours of work, Final
attire, hygiene, use of technology). Assumes responsibility for own actions. 4
Maintains appropriate boundaries in therapeutic and professional relationships.
Midterm 3
Engages in self-reflection
Examples of Performance Indicators: Identifies strengths and areas for
improvement. Accepts constructive feedback and integrates recommendations
Final 4
into practice. Develops and implements learning strategies using appropriate
resources.
Professionalism & Accountability Comments:
I preform in a professional manner at placement, within my PTA role and speak in a respectful manner, i ask
lots of questions when needed.

I could work on feeling more confident to ask more questions than i already do, as well as with taking initiative
without as frequent of assistance. speak and act in a professional way at placement i also stay within my PTA
level of practice and speak to everyone at clinc in a respectful manner

Final thoughts
I feel much more confident on asking for help from the PT supervisors as their job is to help me gain
knowledge and that there is never too many questions that could be asked

I take much more initiative now as the PT asks me to delegate who is seeing what clients for PTA related
tasks, i also try and jump in more when things are not running on time to help anyone out

Reviewed May 2022

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

Communication & Collaboration

Midterm
Communicates in a Professional Manner 4
Examples of Performance Indicators: Establishes rapport. Adapts
communication strategies to reduce communication barriers and support
diversity (e.g. considering education, culture, age and gender). Promotes optimal Final
4
client and team performance (e.g. cueing, providing feedback with dignity and
empathy, listening, guiding)
Midterm
Uses communication skills effectively 3
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
Final
language and terminology suited to the interaction. Uses written communication
in a timely and accurate manner according to workplace expectations (e.g. 4
documenting in clients’ charts, caseload log, taking messages, emails, flow
sheets).
Midterm
Collaborates with Inter-professional Team 3
Examples of Performance Indicators: Recognizes roles of team members.
Participates actively as a team member to optimize client care and provide Final
continuity in service delivery. Consults with/reports to the appropriate team 4
member. Identifies and manages conflict.
Communication and Collaboration Comments:
I make sure to talk to clients in terms they will understand, i frequently make sure they are feeling okay
during ultrasound and while doing their exercises.
I do still get confused on some terms used on charting but it is a work in progress, i also get nervous
when a client lets me know the ultrasound machine feels uncomfortable for them even though it is a very
simple fix of just adjusting the intensity again to work on my confidence in this area.

Final thoughts
I use client centered language when speaking with my clients as well as confirming with the how they
are feeling during our treatment session together
I have gained a better understanding for charting terms which are used in the clinc for charting
I feel very confident in adjusting the settings down if a client feels discomfort using ultrasound, i still get a
little confused when working with the older ultra sound machine as the settings are different but i do
have growth with working with that as well

Reviewed May 2022

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

Treatment Implementation
Midterm
Performs assigned therapeutic interventions (direct patient care) 3
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.
Participates in client education. Implements therapeutic intervention using a Final
client-centred approach. Follows the timing, frequency, location and duration of 4
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.
Midterm
Performs assigned therapeutic interventions (indirect patient care) 4
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,
Final
environmental scan, follows precautions and contraindications). 4

Demonstrates critical thinking Midterm

Examples of Performance Indicators: Integrates knowledge (e.g. anatomy, 3
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,
Final
determines possible options, recognizes risks, implement solution, reflect and 4
revise). Analyzes and interprets information accurately (e.g. chart review)

Protects the client from harm Midterm

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

Treatment Implementation Comments:

I do follow all safety requirements with clients, I also grab things needed for treatment like equipment and
the ultrasound machine

I Need to work on my active recall for anatomy terms, as well as when i get new clients to not be nervous
and just be my confident self.

Final thoughts
I make clients aware of any safety education that is needed especially during ultrasound
I always have the proper equipment for exercises as well as gel and towels for ultrasounds

still working on strengthening my anatomy skills but i do feel some growth in this area since midterm and
feeling more confident since midterm as well in working with clients.

Reviewed May 2022

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

Organization of Service Delivery

Midterm 4
Performs non-clinical duties
Examples of Performance Indicators: Organizes and maintains equipment,
supplies, and written resources. Completes administrative tasks (e.g. workload Final
measurements, scheduling, quality improvement initiatives, inventory). 4
Participates in education of team members, peers, and other learners as
assigned.
Organization of Service Delivery Comments:
I have picked up on daily tasks that should be done such as frequent laundry and wiping down the plinths.

I do from time to time miss wiping down a plinth or two when things get busy as well as i sometimes forget what
all the cleanup tasks at the end of the night are.

Final thoughts
I have become very familiar with daily tasks such as lotion bottle refilling, trash duties, laundry and folding as well
as wiping down plinths and remaking pillows.

Reviewed May 2022

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

General Comments:

Strengths:
Always kind and respectful to everyone, always open for conversations with clients and i am a very hard
worker

Always asks for help when needed

very good at communicating with clients and with my PT supervisors as well as the other students at clinc
great at encouraging patients during their exercises
Areas for growth:

To grow in my confidence in my skills and knowledge

still room to grow in grading how a client is doing during treatment and what changes could be made

The midterm evaluation was reviewed with the student

Clinical Supervisor(s): Date

Print Name / Designation Signature

The midterm evaluation was reviewed with the clinical supervisor

October 22nd 2022

Student Print Name Signature

Student was well prepared for this placement. Yes No

If no, please indicate areas of insufficiency.

Comments:

Reviewed May 2022

 Final Summary of Evaluation of Clinical Competencies
To be completed at the end of the placement only.

General Comments:

Strengths:

Areas for growth:

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

absent: late:
Profession allocation of OTA:PTA
%: %
Reason for absence:

Overall Performance on this Placement:

Exemplary Satisfactory Unsatisfactory (explanation required)

Clinical Supervisor(s):

Print Name / Designation Signature Date

Assigning OT or PT

Print Name / Designation Signature Date

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

Print Name / Designation Signature Dat

Reviewed May 2022