C1.Performance Eval Level I FW: OT Process

Level I Fieldwork Occupational Therapy Process
Spring 2023
Department of Occupational Therapy
University of Central Arkansas

Date * / MM / DD YYYY
Student Name * First Last
Fieldwork Educator/Primary Supervisor Name * First Last
Fieldwork Educator/Primary Supervisor Email Address *
Fieldwork Educator/Supervisor Name (2nd evaluator if needed) First Last
Facility Name *
Facility Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Primary Age of Clients *
Select the Primary Setting for this fieldwork experience. *
If "other" Please describe
Please rate the experience on a scale from 1-5 on the following (make note of ratings to be used most frequently):

5= Far Exceeds Standards:
Student performance was highly skilled and self-initiated. Performance was the best that could be expected from any level I fieldwork student.

4= Exceeds Standards:
Student frequently completed tasks and activities that exceed requirements/objectives.

3= Meets Standards:
Completed required tasks and activities to meet objectives. This rating reflects good performance for a student at this level. (This rating should be used most frequently.)

2= Below Standards:
Student performance is progressing, but need improvement to meet objectives. I did not demonstrate adequate response to feedback. My performance was occasionally unacceptable.

1= Unsatisfactory:
Student performance was poor or frequently unacceptable in most required activities and tasks. I did not met the objectives of this experience.
Student exhibits a professional image (e.g. dresses appropriately for the setting, accepts responsibility for personal actions, etc.). * 5 4 3 2 1
The student demonstrates a respect for time (arrives on time, begins/ends activities/tasks on time, uses time wisely, etc.) * 5 4 3 2 1
Student attends all scheduled on-site days and/or makes appropriate arrangements for missed days. * Yes No Not Applicable
The student demonstrates active participation, interest, and motivation to learn (e.g. asks for help/feedback appropriately, asks appropriate questions, seeks extra learning opportunities, etc.). * 5 4 3 2 1
Student interactions with clients and staff are appropriate and professional. * 5 4 3 2 1
Demonstrates respect for diversity. * 5 4 3 2 1
Student adheres to safety regulations of the facility related to self and others. * 5 4 3 2 1
Student adheres to ethics and confidentiality (HIPAA) during interactions with clients, families, and other professionals. * 5 4 3 2 1
Please rate the student's overall professional behavior. * 5 4 3 2 1
Under supervision, the student demonstrates the ability to use interview and observations with client(s) to collect data as part of the occupational therapy process. * 5 4 3 2 1
Under supervision, the student demonstrates the ability to develop and implement contextually relevant individual and/or group interventions to address psychosocial development and/or behavioral health that affect occupational performance. * 5 4 3 2 1
Under supervision, the student demonstrates the ability to adapt and/or modify processes to reflect the changing needs of the client. * 5 4 3 2 1
Student adjusts and demonstrates carryover of performance based on feedback. * 5 4 3 2 1 Not Applicable
Please rate the student's overall skills and abilities. * 5 4 3 2 1
If applicable, please provide feedback on how the student added value to the site.
Please comment on the student's overall performance, including strengths and areas for improvement: *
Additional Comments:
Acknowledgement
I acknowledge that the person(s) completing this evaluation is/are the fieldwork educators listed above for the student listed above. Furthermore, I/we have reviewed this evaluation with the student as deemed appropriate.
* Yes No
Thank you for serving as a fieldwork educator in partnership with the University of Central Arkansas Department of Occupational Therapy. In appreciation, you will receive a certificate of service to the email listed above. Please allow approximately 6 weeks.

*NOTE: Please print or screen shot this evaluation after clicking on "CONTINUE" and before choosing "SUBMIT". You must click SUBMIT for your evaluation to be received successfully.

C1.Performance Eval Level I FW: OT Process

C1.Performance Eval Level I FW: OT Process

Acknowledgement