Level I Fieldwork Student Evaluation Form PHILADELPHIA REGION FIELDWORK CONSORTIUM LEVEL | FIELDWORK STUDENT EVALUATION Adopted and adapted by Sacred Heart University Graduate Program in Occupational Therapy studentmame_JO2i[? Aragon Supervisor name (print) Nleqan Mele Ms.oTRIt Sitenme:__High Rosd3 School = Walling Foed Date(s) of Fieldwork 2/4, 21, 218. 2125 Indicate the student's level of performance using the scale below. I=Well Below Standards: Performance is weak in most ri 2eBelow Standards: ‘Opportunies Zor improvement response to feedback. ‘Work is occasionally unecespieble. ired tasks and activities. Work is Srequendy ungeceptabe. st however studest has not demonstrated adequate 3+Meets Standards: Cartes out required tasks and activities. This rating represents good, solid performance and should ‘he used moze than all the others. 4oR ceeds Standards: Frequently carries out tasks and activities that surpass requirements, At times, performance: is exceptional S+Far Exceeds Standards: Carries out tasks and activities in consistently outstanding fashion, Performance isthe best that could be 1. Time management Skills Consider ability to be prompt, arrive on time, complete assignments on time. Comments: Qn nme and ready fo werk even, week f 2. Organization 7 Consider ability to set priorities, be dependable, be organized, follow through with responsibilities Comments: Progetive, in accomplishing Ne wesseny tuks on Studer’ chetkhivt 3. Engagement in the fieldwork experience Consider student's apparent level of interest, level of active participation while on site; investment in individuals and treatment outcomes, follows safety precautions. Comments: Very th terated fh Polldiing Student fom week to Week and Foll owieg of on outcomes 4. Self-Directed Learning 2 Consider ability to take responsibility for own learning; demonstrate motivation. Comments: Moqyated € Self-direcked learner Fieldwork Manual 8/41 13Reasoning/Problem solving »asider ability to use self-reflection, willingness to ask questions; ability to Comments: Agked excellent queshars and Independent problem-solved ad Situanens qrase IN SesStane 6. Communication Coneise in written and verbal communication; Consider grammar, spelling, legibility, successful completion of written assignments, documentation skills, positive verbal and non-verbal interpersonal communication skills, assertive. Comments: Excellent Verbal communi cahon SmI and positive interpercanal SkyIls with stident> C analyze, synthesize and interpret information; understand the OT process, 7. Observation Skills. Consider initiative, ability to seek and acquire information ftom a variety of sources; demonstrates flexibility as needed. Comment: 8. Initiative Consider initiative, ability to seek and acquire information from a variety of sources; demonstrates flexibility as needed, seeks to improve, volunteers for additional responsibilities comm ed to review student inFormatan, wert above Aske expecta in Seelvng avd Info / being Flexible Participation in the Supervisory Proces Consider ability to give, receive and respond to feedback; seck guidance when necessary; follow proper channels, modifies performance after feedback. Comments: 10. Interpersonal skills with patients/elients/ | stafiearegivers Consider ability to interact appropriately with individuals, such as eye contact, empathy, limit setting, respectfulness, use of authority, etc; degree/quality of verbal | interactions; use of body language and non-verbal communication; exhibits | confidence, respects diversity. ‘Comments: 11. Professional and Personal Boundaries | Consider ability to recognize/handle personal/professional frustrations; balance personal/professional obligations; handle responsibilities; work w/others cooperatively, considerately, effectively; responsiveness to social cues. Comments: Able to reach Subtle cucs € respend appropnisicly when ehgaged © clients (Sfudents) ppropnatcly IF 12346 12. Professional Behaviors/Responsibilities Field Manual 844 4Cor terminology (such as the Practice Framework, acronyms, abbreviations, etc) in written and oral communication; demonstrates an awareness of/follows AOTA Code of Ethics. Comments: Teelle 1s profesional ymoNvated and ler ability to respect confidentiality; appropriately apply professional enthusiashe clr occupehonal therspy | 12 3@s Final score: OS [fas [ ] Fail Requirements for passing: Student signature No No more than one item below a "2", OR ‘more than two items below a "3", Supervisor signature_[Y\e-q ye YY\ eho M5 OTeu|t © Philadelphia Region Fieldwork Consortium Letter Grade Progression Grade Points| Deseription A 38-60 | Must score at least a3” in 10 categories and "4" in two categories or “3” in 11 categories and a “5” in one category a 37 ‘Must score at least a “3” in 17 categories and “4 in one category Be 36 “Must score at least a°3 in all 12 categories B 33 ‘Must score at least a “3” in 11 categories and “2* in two categories B- 34 Must score at least a “3” in 10 categories and “2” in 2 categories Fail 35 points oF less or no more than one item below a “2” or no more than two items below age Please note that your grade may be modified by the AFC based on your performance in Level I Fieldwork meetings, professional behaviors surrounding rules and requirements for level I FW including attendance, communication with AFC, written assignments, deadlines for paperwork, and other specifics outlined in the student manual and or syllabus. Fieldwork Manual 8/1 16Level | Fieldwork Student Evaluation Form =evel | Fieldwork Student Evaluation Form PHILADELPHIA REGION FIELDWORK CONSORTIUM LEVEL I FIELDWORK STUDENT EVALUATION Adopted Student name_ JDC. and adapted by Sacred Heart University Graduate Program in Occupational Therapy Supervisor name (print), eee ca Sesn Zz Site name: BOL Date(s) of Fieldwork Indicate the student's level of performance using the scale below. ‘Well Below Standards: !=Below Standards: feedback. Work is occasionally unacceptable, ‘S-Meets Standards: Performance is weak in most re Opportunities for improvement, Carries out required tasks and actiit LB1UFIECY, 07> quired tasks end etiities. Work s frequently unecceptable. ‘exist howover student has not demonstrated adequate response to be used more than all he others. AeExceeds Standards: exceptional. ‘SeFar Exceeds Standards: Carves ou: tasks and activities beexpected tom any student. |. Time management Skills Froquenty carries out tasks and activities thet surpas requirements ics. This rating represents good, solid performance and should Atties, peeformance is jn consistently outstanding fishion, Performance isthe best that could Consider ability to be prompt, arrive on time, complete assignments on time, Comments: . Organization Consider ability to set priorities, responsibilities Comments: be dependable, be organized, follow through with . Engagement in the fieldwork experience Consider student's apparent level of interest, level site; investment in individuals and eae densely oguta ay mignigs: & exter Dueshecl ins otf pabeah Jorhomel. |. Self-Directed Learning of active participation while on ‘treatment outcomes, follows safety precautions, Lb Consider ability to take responsibility for own leaming; demonstrate motivation. come ith gap ze Comments: Sch cook fees ban ag Tew 1624 20 12845 12@455. Reasoning/Problem solving Consider ability to use self-reflection, willingness to ask questions; ability to analyze, synthesize and interpret information; understand the OT process. Comments: 6 Communication Concise in writien and verbal communication; Consider grammar, spelling, legibility, successful completion of written assignments, documentation skills, positive verbal and non-verbal interpersonal communigation skills, assertive. Comments: WS Aare, a poli 7 la fovee Hol pobontt, were, comUpibhe, yprspn! é ohuinalia hie) o altiteea! wahericmn’ seattle, 7. Observation Skills. Consider initiative, ability to seek and acquire information from a variety of sources; demonstrates flexibility as needed. ‘Comments: Consider initiative, ability to seek and acquire information from a variety of sources; demonstrates flexibility as needed, seeks to improve, volunteers for additional responsibilities. Comments: 9. Participation in the Supervisory Process Consider ability to give, receive and respond to feedback; seek guidance when necessary; follow proper channels, modifies performance after : feedback Bho veay, polibue, oh freclbuch. Comments: 10. Interpersonal skills with patients/clients/ staff/earegivers Consider ability to interact appropriately with individuals, such as eye contact, empathy, limit setting, respectfulness, use of authority, etc; degree/quality of verbal interactions; use of body language and non-verbal communication; exhibits confidence, respects Pla Dil a eek, Job in tht area —She 17 Comments: a ve heal perlary ~ ell bea Se ee ee 11. Professionsf and Personal Boundaries Consider ability to recognize/handle personal/professional frustrations; balance personal/professional obligations; handle responsibilities; work wiothers cooperatively,‘considerately, effectively; responsiveness to social cues, Comments: | 12. Professional Behaviors/Responsibilities 12045 Consider ability to respect confidentiality; appropriately apply professional terminology (such as the Practice Framework, acronyms, abbreviations, eto) in written | and oral communication; demonstrates an awareness of/follows AOTA Code of Ethics. | ‘Comments: | Final score: 4 eee Requirements for passing: TAPass [ ]Fail cy < Student signature ‘No more than one item below a "2", OR ‘No more than two items below a "3". Supervisor signature © Philadelpiia Region Fieldwork Consortium Letter Grade Progression Grade Points| Deseription A 38-60 | Must score at least a “3” in 10 categories and "4" in two categories or “3” in 1] categories and a “5” in one category { AS 37 ‘Must scare at least a “3” in 1] categories and “4 in one category BE 36 ‘Must score at least a “3 in all 12 categories B 35 ‘Must score at least a “3” in 11 categories and “2” in two categories | | B. 34 ‘Must score at least a “3” in 10 categories and “2” in 2 categories | Fail 33 points or less or no more than one item below a “2” or no more than two items below | ae Picase note that your grade may be modified by the AFC based on your performance in Level I Fieldwork meetings, professional behaviors surrounding rules and requirements for level I FW including attendance, communication with AFC, written assignments, deadlines for paperwork, ahd other specifics outlined in the student manual and or syllabus,al | Fieldwe ident Evaluation Form PHILADELPHIA REGION FIELDWORK CONSORTIUM LEVEL | FIELDWORK STUDENT EVALUATION Adopted and adapted by Sacred Heart University Graduate Program in Occupational Therapy Student name “Noelle Atkinson ‘Supervisor name (print) Kor Leo. Sitename: S@\eck Plrssicod Dd Date(s) of Fieldwork Z4 6 — ie Indicate the student's level of performance using the scale below. I-Well Below Standards: Perforce is weak fa most raquired tasks and acivitee. Work is equeat¥y unacceptable, 2Below Standards: Opportunities for inprovement exist however student has not demonseted adequate response ‘bedbeck, ‘Work is occasionally unacceptable ‘3+Meets Standards: (Carries out required tasks and activities. This rating represects good, slid performunce and ahould, ‘de used more then all the otters, 4-Bxcends Standards: Frequently caries cut tasks and activities thet surpass requirements. At tines, performance is sxeeptional, ‘SeRar Exceeds Standards: Cares ur tans ead activites in consistently ousstendingfechion. Pecforence isthe best chet could De expected from any stent. ‘Time management Sills ~ Consider ability to be prompt, arrive on time, complete assignments on time. Comments: 12@)4 5 Organization Consider ability to set priorities, be dependable, be organized, follow through with responsibilities Comments: ‘Engagement in the fieldwork experience Consider student's apparent level of interest, level of active participation wi Self-Directed Learning Consider ability to take responsiiity for own leaming; demonstrate motivation 4, Comments: Foss, CMPDOCe— Ay aN of CHOY3. Reasoning?Problem solving Consider ability to use self-reflection, willingness to ask questions; ability to analyze, synthesize and interpret information; understand the OT process. ‘Comments: 23@5 6. Communication Concise in written and verbal communicetion; Consider grammer, spelling, legibility, successful completion of written assigaments, documentation skills, positive verbal end non-verbal interpersonal communication skills, assertive. Comments: 7. Observation Skills. Consider initiative, bility to seek ond acquire informetion ftom a variety sources; demonstrates flexibility as needed. Comments: 8. Initiative Consider initiative, ability to seek and acquire information from a variety of sources; ‘as needed, seeks to improve, volunteers for additional 9. Participation in the Supervisory Process Consider ability to give, receive and respond to feedback; seek guidance when necessary; follow proper channels, modifies performance efter feedback. | Comments: 10. Interpersonal skills with patients/clients/ | | staff/caregivers Consider ability to interact appropriately with individuals, such as eye contact, empathy, limit setting, respectfulness, use of authority, etc; degree/quality of verbal interactions; use of body language and non-verbel communication; exhibits confidence, respects. | diversity. ¥ ce Comments: foe ie WROTE CLE) ost ree Story GRGESOHIONS COTVeus WHEW ™S— IL: Professional and Personal Boundaries Consider ability to recognize/handle personal/professional frustrations; balance |__personel/professional obligations; handle responsibilities; work wiothers cooperatively, |considerately, effectively; responsiveness to social cues. ; 1 Comments: \ | 12. Professional Behaviors/Responsibilities Consider ability to respect confidentiality; appropriately apply professional terminology (such as the Practice Framework, acronyms, abbreviations, etc) in written and oral communication; demonstrates an awareness offfollows AOTA Code of Ethics. Comments: | [Final sore: AAD Kass [ J Fail | Requirements for passing: Student signeture * No more than one item below a "2", OR * No more than two items below a Melle SO O pleasue to ove in Seldworkl © Philadeipiie Region Fieldwork Consortiam Letter Grade Progression Grate Points Description ] | SS) 38-60 | Must score at least a “3” in 10 categories and “4” in two categories or “3” in 1] categories and a “5” in one category = A jiseeaaea7) ‘Must score at least a “3” in 17 categories and “4 in one category Be 36 ‘Mast score at least a “3 in all 12 categories B 35 | Must score at least 2 “3” in 11 cates jories and “2” in two cate; gOTies Be 34 ___| Must score at least 2 “3” in 10 categories and “2” in 2 categories Fall 33 points of less or no more than one item below a2” or no more than two items below a3” | Please note that your grade may be modified by the AFC besed on your performance in Level I Fieldwork meetings, professional behaviors surrounding rules and requirements for level I FW including attendance, communication with AFC, written assigaments, deadlines for paperwork, ahd other specifies outlined in the student manual and or syllabus.Level | Fieldwork Student Evaluation Form PHILADELPHIA REGION FIELDWORK CONSORTIUM LEVEL | FIELDWORK STUDENT EVALUATION Adopted and adapted by Sacred Heart University Graduate Program in Occupational Therapy Student name. | At OM aes Supervisor name (print), Crae Akerso 1 Site uamer Colebrating Chidren Date(s) of Fieldwork, 10] 7 -!12)5 Indicate the student's level of performance using the scale below. |. Self-Directed Learning tewel Below Standards: Performance is weak in mos required tasks and ecto, Works Bequentiy wnacoxpiabie. 2-Below Standards Cpr for provement exis Rowover tudent bas ot enoastatlalequae response to feotback Werk is cccaonalis uasccoable 3-Mowts Standards: cee Seiguued tks nd ancvides, This ating represen ood sali pexfomance and should beset mor tan all ear 4-txceeds Standards: Projucly cris out tas end acts tat cupassrguremeats, Atte, performance fs S-Far Exceeds Standards: assed acto inconsistently outstanding fasion. Perfrmance st bes that cule expect’ from sy tuck |. Time management Skills a Consider ability to be prompt, arrive on time, complete assignments on time. 12845 Comments: . Organization - ee Consider ability to set priorities, be dependable, be organized, follow through with 12Q45 responsibilities Comments: , Engagement in the fieldwork experience ae Consider student's apparent level of interest, level of active participation while on site; investment in individuals and Saxena cujcomes follpws safety precautions Comments: Joedle hao ia ve | eu dyad \ Consider ability to take responsibility for own Jearning; demonstrate motivation, 123@ Comments:5. Reasoning/Problem solving Consider ability to use self-reflection, willingness to ask questions; ability to analyze, synthesize and interpret information; understand the OT process. Comments: 6, Communication Concise in written and verbal communication; Consider grammar, spelling, legibility, successful completion of written assignments, documentation skills, positive verbal and non-verbal interpersonal communication skilis, assertive. Comments: ‘Observation Skills. Consider initiative, ability to seek and acquire information from a variety of sources; demonstrates flexibility as needed, Comments: 2@45 8. Initiative Consider initiative, ability to seek and acquire information from a variety of sources; demonstrates flexibility as needed, secks to improve, volunteers for additional Can fag ie asks to Ao crore Sha i oo ee ono atu ate ane % cn in the Supervisory Process Consider ability to give, receive and respond to feedback; seek guidance when necessary; follow proper channels, modifies performance after feedback. Comments: 23@s | 10. Interpersonal skills with patients/clients/ staff/caregivers Consider ability to interact appropriately with individuals, such as eye contact, empathy, limit setting, respectfiulness, use of authority, ete; degree/quality of verbal interactions; use of body language and non-verbal communication; exhibits confidence, respects diversity. Comments: / 11: Professional and Personal Boundaries Consider ability to recognize/handle personal/professional frustrations; balance personal/professional obligations; handle responsibilities; work w/others cooperatively,considerately, effectively; responsiveness to social cues. Comments: 12, Professional Behaviors/Responsibilities Consider ability to respect confidentiality; appropriately apply professional terminology (such as the Practice Framework, acronyms, abbreviations, etc) in written and oral communication; demonstrates an awareness ofifollows AOTA Code of Ethics. Comments: Final score: BO {Pass | ) Fail = Requirements for passing: Student signature * Nomore than one item below a "2", OR * No more than two items below a"3". Supervisor signature Ch BLO" 18 Akardn nsae le © Philadelphia Region Fieldwork Consortium Letter Grade Progression Grade Points | Description A 38-60 | Must score at least a“3" in 10 categories and “4” in two calogoties or “3” in 11 categories and a “5” in one category x 7 ‘Must score af least a “3” in 1] categories and “4 in one calegory Br 36 ‘Must score at least a “3 in all 12 categories B 35 Must score at least a “3” in 11 categories and "2" in two categories Be 34 Must score at least a “37 in 10 categories and “2” in 2 categories Fail 33 points or less or no more than one item below a “2* or no more than two items below a3 Please note that your grade may be modified by the AFC based on your performance in Level I Fieldwork meetings, professional behaviors surrounding rules and requirements for level 1 FW including attendance, communication with AFC, written assignments, deadlines for paperwork, ‘ed other specifics outlined in the student manual and or syllabus.