C1.Performance Eval Level I FW: OT Process 2023

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 1-4 on the following:

4 — Exemplary Performance: Demonstrates satisfactory competence in specific skills consistently; demonstrates substantial breadth and depth in understanding and/or skillful application of fundamental knowledge and skills.

3 — Proficient Performance: Demonstrates satisfactory competence in specific skills; demonstrates adequate understanding and/or application of fundamental knowledge and skills. This rating should be used most frequently.

2 — Emerging Performance: Demonstrates limited competence in specific skills (inconsistencies may be evident); demonstrates limited understanding and/or application of fundamental knowledge and skills (displays some gaps and/or inaccuracies). This is an acceptable rating for clinical skills/abilities for this fieldwork experience.

1 — Unsatisfactory Performance: Fails to demonstrate competence in specific skills; performs in an inappropriate manner; demonstrates inadequate understanding and/or application of fundamental knowledge and skills; (demonstrates significant gaps and/or inaccuracies).
Student exhibits a professional image (e.g. dresses appropriately for the setting, accepts responsibility for personal actions, etc.). * 4 - Exemplary Performance 3 - Proficient Performance 2 - Emerging Performance 1 - Unsatisfactory Performance
The student demonstrates a respect for time (arrives on time, begins/ends activities/tasks on time, uses time wisely, etc.) * 4 - Exemplary Performance 3 - Proficient Performance 2 - Emerging Performance 1 - Unsatisfactory Performance
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.). * 4 - Exemplary Performance 3 - Proficient Performance 2 - Emerging Performance 1 - Unsatisfactory Performance
Student interactions with clients and staff are appropriate and professional. * 4 - Exemplary Performance 3 - Proficient Performance 2 - Emerging Performance 1 - Unsatisfactory Performance
Demonstrates respect for diversity. * 4 - Exemplary Performance 3 - Proficient Performance 2 - Emerging Performance 1 - Unsatisfactory Performance
Student adheres to safety regulations of the facility related to self and others. * 4 - Exemplary Performance 3 - Proficient Performance 2 - Emerging Performance 1 - Unsatisfactory Performance
Student adheres to ethics and confidentiality (HIPAA) during interactions with clients, families, and other professionals. * 4 - Exemplary Performance 3 - Proficient Performance 2 - Emerging Performance 1 - Unsatisfactory Performance
Please rate the student's overall professional behavior. * 4 - Exemplary Performance 3 - Proficient Performance 2 - Emerging Performance 1 - Unsatisfactory Performance
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. * 4 - Exemplary Performance 3 - Proficient Performance 2 - Emerging Performance 1 - Unsatisfactory Performance
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. * 4 - Exemplary Performance 3 - Proficient Performance 2 - Emerging Performance 1 - Unsatisfactory Performance
Under supervision, the student demonstrates the ability to adapt and/or modify processes to reflect the changing needs of the client. * 4 - Exemplary Performance 3 - Proficient Performance 2 - Emerging Performance 1 - Unsatisfactory Performance
Student adjusts and demonstrates carryover of performance based on feedback. * 4 - Exemplary Performance 3 - Proficient Performance 2 - Emerging Performance 1 - Unsatisfactory Performance
Please rate the student's overall skills and abilities. * 4 - Exemplary Performance 3 - Proficient Performance 2 - Emerging Performance 1 - Unsatisfactory Performance
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.

Please indicate the name and email address for each person who provided weekly supervision for the occupational therapy students. This information will be taken as it is typed for the certificates. Please include credentials as part of the last name if you would like that included on the certificate. Thank you!

Name First Last
Email
Name First Last
Email
Name First Last
Email
Name First Last
Email
Name First Last
Email
*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 2023

C1.Performance Eval Level I FW: OT Process 2023

Acknowledgement

*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.