Canadian OTA and/or PTA Student Fieldwork

Evaluation Form

Student’s Name: Merin Mathew

Placement ☒ Field Placement I ☐ Field Placement II

☐ Block Placement
Durham College Advisor
Name:
Clinical Supervisor’s Name Rahim Virji, O.T. Reg., (Ont.)
Clinical Supervisor’s
OT
Designation:
Village of Taunton Mills LTC and RH
Name of Facility
☒OTA
Discipline Focused on ☐PTA
During Placement: ☐OTA & PTA
Ratio OTA:PTA Click here to enter text.%
☐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 Coordinator

▪ Via mail to:
Teresa Avvampato, OTA/PTA Program
School of Health and Community Services
Durham College
2000 Simcoe Street N
Oshawa, On, Canada, L1H 7K4

▪ Via email or fax with original form followed in mail.

▪ Via your assigned advisor

*** Please note for tracking hours, please sign the Attendance Form (pg. 11-12) and students will
take an electronic copy and submit this to demonstrate completion of the required hours – this
must be received within 24 hours following placement completion ***

Reviewed March 30, 2022 Page 1 of 10

 Expectations for Student Performance
Clinical Supervisors are to progress the student from basic practice principles and
techniques to “entry level” within the area of practice. Please note that students may be
in the second year of their training, however, they may be experiencing a particular area of
practice (eg. acute medicine) for the first time on this placement. This student’s
development will therefore represent a basics-to-entry-level progression pattern despite
their status within the program overall.

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.
▪ Comment(s) on the student’s performance provide valuable insight and feedback on how the student is
performing at this placement. Providing comments at midterm and final evaluations will assist the student
to improve their performance.
▪ Midterm and Final Summary Pages are completed at midterm and end of placement.
▪ Signatures of the clinical supervisor(s) and student must be provided on the form.
▪ If the clinical supervisor is an Assistant, the therapist assigning the duties to their Assistant
must also sign the form.

Rating Scale:
Competency Rating Scale & Descriptors
Student can consistently and reliably perform competency/skill
5 Independent independently at entry-level1 practice, following clinical supervisor’s
instruction, within this specific practice setting.
Student can perform the competency/skill with occasional (minimal)
Approaching
4 guidance, support, and/or direction from Clinical Supervisor (OTA/OT
independence
and/or PTA/PT)
Student demonstrates significant gains in the acquisition of skills and
Acquiring
3 knowledge related to the role. Student can perform competency/skill
independence
with regular (moderate) guidance, support, and/or direction
Student demonstrates a basic understanding of skills and knowledge
Emerging
2 related to the role. Student can perform competency/skill with
independence
continuous (maximum) guidance, support, and/or direction
Student demonstrates poor /a lack of understanding of skills and
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 prior to
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 March 30, 2022 Page 2 of 10
Rating Scale: 5: Independent, 4: Approaching independence, 3: Acquiring independence,
2: Emerging independence, 1: Unsatisfactory

Professionalism & Accountability

2
Midterm
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 3
Final
within personal abilities and limitations. Seeks support / assistance
appropriately. Asks appropriate questions. Follows supervision and
communication guidelines.
Mid-term comments

Good understanding of role in placement. Asks relevant questions and seeks support in timely and relevant
manner.

Final comments

Excellent improvement noted. Merin seems to feel much more comfortable with clients and her role.

2
Midterm
Takes responsibility for service components as assigned
Examples of Performance Indicators: Prioritizes assigned duties and resources 3
appropriately. Demonstrates effective time management skills. Final

Mid-term Comments
Good time management and accountability.

Final comments

Very good! Very little supervision required r/t time management skills.

2
Midterm
Demonstrates professional behaviors
Examples of Performance Indicators: Exhibits respect, initiative and enthusiasm.
Follows workplace expectations (e.g. policies and procedures, hours of work, 3
Final
attire, hygiene, use of technology). Assumes responsibility for own actions.
Maintains appropriate boundaries in therapeutic and professional relationships.
Mid-term Comments

No issues apparent thus far in placement. Good acceptance of responsibilities for her own actions. Very
engaging and passionate about working with residents and Merin is responding well to preceptor coaching.

Final comments

Very good improvement observed since mid-term. Meets expectations of professional behaviors very well.

Professionalism & Accountability

2
Midterm
Engages in self-reflection
Rating Scale: 5: Independent, 4: Approaching independence, 3: Acquiring independence,
2: Emerging independence, 1: Unsatisfactory

Examples of Performance Indicators: Identifies strengths and areas for 3

Final
improvement. Accepts constructive feedback and integrates recommendations
into practice. Develops and implements learning strategies using appropriate
resources.
Mid-term comments

Good response to preceptor feedback about understanding how important self-reflection is and how it can effect
the success her practice.

Final comments

Merin is very engaged with her residents and has demonstrated an excellent improvement in accepting
constructive feedback and improving her desire to bring new ideas to preceptor after reflecting more since mid-
term.

Reviewed March 30, 2022 Page 4 of 10

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

Communication & Collaboration

2
Midterm
Communicates in a Professional Manner
Examples of Performance Indicators: Establishes rapport. Adapts
communication strategies to reduce communication barriers and support 3
diversity (e.g. considering education, culture, age and gender). Promotes optimal Final
client and team performance (e.g. cueing, providing feedback with dignity and
empathy, listening, guiding)
Mid-term comments
Good communication with peers and preceptor. Merin has strong confidence and communicates well because of
it.

Final comments

Noticeable improvement noted in Merin’s ability to interact and communicate effectively with her residents. She
has grown even more confident and this is evident when she executes treatment plans.

Uses communication skills effectively 2

Midterm
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
language and terminology suited to the interaction. Uses written communication 3
Final
in a timely and accurate manner according to workplace expectations (e.g.
documenting in clients’ charts, caseload log, taking messages, emails, flow
sheets).
Mid-term comments

SOAP note writing needs moderate re-writing based on feedback from preceptor. But very much on the right
path with diligence and attentive to coaching from preceptor.

Final comments

Significant improvement noted in Merin’s SOAP note writing. No corrections are required by final evaluation.

Collaborates with Inter-professional Team 2

Midterm
Examples of Performance Indicators: Recognizes roles of team members.
Participates actively as a team member to optimize client care and provide 3
continuity in service delivery. Consults with/reports to the appropriate team Final
member. Identifies and manages conflict.

Mid-term comments
Very good collaboration with others demonstrated. Coaching has been provided for improvement in this area.

Final comments
Merin has demonstrated outstanding improvement and has shown that she can work well in a collaborative team setting
numerous times since mid-term. Well done!

Reviewed March 30, 2022 Page 5 of 10

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

Treatment Implementation
Competency: 2
Midterm
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. 3
Participates in client education. Implements therapeutic intervention using a Final
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.
Mid-term comments

Basic skill level: requiring some guidance from preceptor. Sometimes is unsure of how to engage with resident
when resident is not fully participatory. Guidance provided and Merin has responded well.

Final comments

Merin has demonstrated excellent improvement in her patient care since mid-term. Her confidence has
improved. She follows OT treatment plan effectively and with greater confidence. She is able to discern the
resident’s condition and how it may effect that days’ treatment efficacy and outcome. Well done!

Competency: 2
Midterm
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, 3
Final
environmental scan, follows precautions and contraindications).

Mid-term comments

Good.

Final comments
Very good.

Reviewed March 30, 2022 Page 6 of 10

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

Treatment Implementation
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)

Mid-term comments
Some coaching needs identified in her clinical understanding of occupational therapy and how it relates to
various different health conditions. But Merin has been quite expressive in asking questions and seems to be
learning well from preceptor feedback and guidance.

Final comments

Merin has shown outstanding improvement in thinking critically and analyzing information as it pertains to OTA
work. Great positive gains since mid-term.

Protects the client from harm 2

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

Mid-term Comments

Good.

Final comments

Much improved.

Reviewed March 30, 2022 Page 7 of 10

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

Organization of Service Delivery

Competency: 2
Midterm
Performs non-clinical duties
Examples of Performance Indicators: Organizes and maintains equipment,
supplies, and written resources. Completes administrative tasks (e.g. workload 3
Final
measurements, scheduling, quality improvement initiatives, inventory).
Participates in education of team members, peers, and other learners as
assigned.
Mid-term comments

Good.

Final comments

Very good!

Reviewed March 30, 2022 Page 8 of 10

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

General Comments:

Strengths:

- Asks relevant questions

- Accepts feedback well from preceptor.
- Good organizational skills
- Punctual
- Perfect attendance

Areas for growth:

The midterm evaluation was reviewed with the student

Clinical Supervisor(s): Date

Rahim Virji_____________ ___ ____________March 7, 2022______

Print Name / Designation Signature

The midterm evaluation was reviewed with the clinical supervisor

______________________ ______________________ _____________________

Student Print Name Signature

Student was well prepared for this placement. Yes No

If no, please indicate areas of insufficiency.

Comments:

Reviewed March 30, 2022 Page 9 of 10

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

General Comments:

Strengths:

- Well organized.
- Comes prepared.
- Willingness to learn.
- Good personality
- Continues to ask questions and learns well from them
- Good insight into her role and how it helps residents.

Areas for growth:

- Continue working on critical thinking skills and reflection.

- Expand knowledge of various OT interventions as they pertain to OT work in different settings.

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

absent: 0 late: 0 ____152________

Profession allocation of OTA:PTA

_100_____%:______%
Reason for absence:

Overall Performance on this Placement:

Exemplary Satisfactory Unsatisfactory (explanation required)

Clinical Supervisor(s): Date

Rahim Virji, O.T. Preceptor ____ ____March 30, 2022

Print Name / Designation Signature

______________________ ______________________ _____________________

Print Name / Designation Signature

Supervising OT or PT
Reviewed March 30, 2022 Page 10 of 10