Canadian OTA and/or PTA Student

2021-2022 Fieldwork Evaluation Form

Madison Hamlyn
Student’s Name:

Placement □ Field Placement I ☐ Field Placement II

□ Block Placement
Durham College Advisor
Name: Laura Maybury
Clinical Supervisor’s Name
Dunika Dissanayake
Clinical Supervisor’s
Designation: Physiotherapist
Name of Facility NeuroChangers
☐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

Revised March 30, 2020

 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).

Revised March 30, 2020

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

Professionalism & Accountability

Midterm 3
Practices within scope of professional parameters and personal abilities
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 4
Final
within personal abilities and limitations. Seeks support / assistance
appropriately. Asks appropriate questions. Follows supervision and
communication guidelines.

Takes responsibility for service components as assigned

Midterm
2
Examples of Performance Indicators: Prioritizes assigned duties and resources
appropriately. Demonstrates effective time management skills. Final
4
Midterm 3
Demonstrates professional behaviors
Examples of Performance Indicators: Exhibits respect, initiative and enthusiasm.
Follows workplace expectations (e.g. policies and procedures, hours of work, Final 4
attire, hygiene, use of technology). Assumes responsibility for own actions.
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 4
Final
into practice. Develops and implements learning strategies using appropriate
resources.
Professionalism & Accountability Comments:
Madison is profesional and does a great job with following assigned tasks. She stays within
her role as a PTA and is great at asking for support when she is uncomfortable completing a
task. She is respectful to all of our clients and is enthusiastic about learning. Madison needs
guidance regarding how to spend time throughout the day (ie. which clients to observe/assist
and what to do during breaks).

Madison has demonstrated more independence in the professionalism and accountability

categories. She has done well with creating a daily plan of which clients she will be assisting
and what she will be doing during her down time. She has taken the feedback from her
midterm and used it well to improve her skills. Our clients have loved having her around!

Revised March 30, 2020

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

Communication & Collaboration

Midterm 3
Communicates in a Professional Manner
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 2
Uses communication skills effectively
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 3
Final
language and terminology suited to the interaction. Uses written communication
in a timely and accurate manner according to workplace expectations (e.g.
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 4
continuity in service delivery. Consults with/reports to the appropriate team
member. Identifies and manages conflict.
Communication and Collaboration Comments:
Madison does well with making clients feel welcome and comfortable. She is very easy to talk to and is able to
communicate well with clients. Madison needs guidance on how to teach specific exercises to clients and cue
their form. Madison has done well with charting but needs guidance on depth of information written in notes along
with summarizing the assessment section. Madison works well with the other team members and has been
learning how to assist with front desk and phone duties while working alongside the clinic administrator.

Madison has improved her ability to communite with our clients during their sessions. She has become more
efficient with charting and was able to create a written exercise program with pictures and descriptions using
exercises performed with a client. Madison does well to work with our administrator and high school student to
assist with the front desk duties during her down time.

Revised March 30, 2020

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

Treatment Implementation
Midterm 2
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.
Participates in client education. Implements therapeutic intervention using a Final 3
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.
Midterm 2
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,
Final
environmental scan, follows precautions and contraindications). 3
Demonstrates critical thinking Midterm 2
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, 3
Final
determines possible options, recognizes risks, implement solution, reflect and
revise). Analyzes and interprets information accurately (e.g. chart review)

Protects the client from harm Midterm 2

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.
safe use of equipment, infection control, correct handling techniques, draping, 3
Final
privacy)

Treatment Implementation Comments:

Madison needs guidance on how to assist clients with hands-on tasks (ie. exercises, transfers,
etc) along with preparing and planning for treatments. She can be uncertain when asked
questions regarding anatomy and kinesiology/biomechanics, and needs assistance to
describe how to perform various manual handling techniques (ie. transfers, bed mobility, sit to
stand, etc). However Madison is showing that she can very learn well when given support,
time, and repetitions. She follows directions well and is able to assist clients with tasks after
being shown the proper method.

Madison has improved with her ability to direct care with moderate assistance. While she can
be nervous regarding manual handling and teaching exercises, Madison does well once she is
given assistance and a demonstration. Her knowledge of joint motions and muscle actions has
improved throughout the placement, and Madison has been able to think more critically about
why we are working on specific movements with clients.

Revised March 30, 2020

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

Organization of Service Delivery

Midterm 3
Performs non-clinical duties
Examples of Performance Indicators: Organizes and maintains equipment,
supplies, and written resources. Completes administrative tasks (e.g. workload Final 5
measurements, scheduling, quality improvement initiatives, inventory).
Participates in education of team members, peers, and other learners as
assigned.
Organization of Service Delivery Comments:
Madison has done well with non-clinical duties. She has no issues with performing cleaning,
laundry, and administrative tasks with some guidance and prompting.

Madison has become a lot more independent with performing non-clinical duties. By the end
of her placement, I didn't have to ask Madison to find non-clinical tasks to complete during her
down time as she would already be doing them.

Revised March 30, 2020

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

General Comments:
Madison has been doing well for her first placement and she is progressing at a good rate. She has been
inquisitive and eager to learn while ensuring she isn't performing duties outside of her scope or level of
comfort. She has had difficulty since receiving a concussion during her second week of placement - this has
required us to modify her day to allow for regular breaks. However despite her symptoms, she has still made
herself available to assist with treatments and clinic duties. Overall she has been a joy to have in the clinic
and I am looking forward to continuing to see her growth in this field.

Strengths:
Madison is great at identifying what she is uncomfortable with and doesn't hesitate to ask
questions or ask for a technique to be demonstrated before trying it herself. Once
discussed/demonstrated, Madison is able to try the assigned task and has been improving
in her abilities each week. She is very willing to learn.

Areas for growth:

Anatomy and biomechanics (ie. muscle actions and their relavance to a functional
movement, concentric/eccentric/isometric contractions, how gravity affects movements
and muscle actions).
Independence with planning her day (clinical and non-clinical tasks), creating exercise
plans, completing charting

The midterm evaluation was reviewed with the student

Clinical Supervisor(s): Date

Dunika Dissanayake/Physiotherapist Feb 23 2022
Print Name / Designation Signature

The midterm evaluation was reviewed with the clinical supervisor

Madison Hamlyn Feb 23 2022

Student Print Name Signature

Student was well prepared for this placement. Yes No

If no, please indicate areas of insufficiency.

Comments:

Reviewed May 11, 2020

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

General Comments:
Madison has done very well for her first placement despite her health concerns. She has really done well with
using her midterm feedback to improve her skills. She has come very far since her first week of placement and
I'm confident she will continue to grow further and be a huge asset to this profession!

Strengths:
Madison does well with the feedback and constructive criticism she is given and uses it to better her skills. She
has had a tough placement due to her health but she has perservered well and put herself outside of her comfort
zone to learn more. Creating a daily timetable to plan out her day really assisted with her independence and
made my life easier as I knew she was thinking about what she had to do throughout the day, rather than waiting
for me to assign her with duties. Madison relates well to people and is a quick and eager learner.

Areas for growth:

Anatomy and biomechanics (although this has improved a lot since the start of her placement!)
Manual handling (assisting with transfers, bed mobility, walking, etc)
Clearly and confidently communicating exercise/treatment plans

Attendance: No. of days No. of days Total hours completed at placement: 149

absent: late:
Profession allocation of OTA:PTA
2 0 %: 100 %
Reason for absence:
Health issues
Overall Performance on this Placement:
Exemplary Satisfactory Unsatisfactory (explanation required)

Clinical Supervisor(s):

Dunika Dissanayake/Physiotherapist Apr 1 2022

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 11, 2020