Canadian OTA and/or PTA Student
2022-2023 Fieldwork Evaluation Form
Madison Hamlyn
Student’s Name:
Placement □ Field Placement I ☐ Field Placement II
□ Block Placement
Durham College Advisor
Name: Teresa Avampato
Clinical Supervisor’s Name
Kathy Sparrow, Louise Stofberg
Clinical Supervisor’s
Designation:
Name of Facility Fine Motor Clinic Durham College
☐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 4
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 3.5
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
4
Examples of Performance Indicators: Prioritizes assigned duties and resources
appropriately. Demonstrates effective time management skills. Final
4
Midterm 4
Demonstrates professional behaviors
Examples of Performance Indicators: Exhibits respect, initiative and enthusiasm.
Follows workplace expectations (e.g. policies and procedures, hours of work, Final 3.5
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 3.5
Final
into practice. Develops and implements learning strategies using appropriate
resources.
Professionalism & Accountability Comments:
some things i feel i did well on are prioritizing my assigned duties such as submiting treatment plans on time,
completing SOAP notes before the end of the day and asking questions when required. things i could work on
are, my initiative when going into treatment sessions i feel something unorganized and unprepaired for treatment
sessions and i can work on asking for help when needed
Final; things i did well on is completing my SOAP notes and my treatment plans on time and enbedding feeback
into my treatment plans to enhance them to the best of their ability, i always respect children and parents at all
times and i always arrive on time and ready to participate
Some things i could work on would be my confidence during treatment sessions and taking initiativeduring group
activities and during our online time when our preceptor asks us questions
Revised March 30, 2020
Rating Scale: 5: Independent, 4: Approaching independence, 3: Acquiring independence,
2: Emerging independence, 1: Unsatisfactory
Communication & Collaboration
Midterm 4
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 4
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 4
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 4
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:
things i did well on are, effectivly communicating my confusion or when i am unsure of a task, i am effective when it comes to
communicating to parents regarding child's progress and tip and tricks they can do from home. i also think i have done a good
job when communicating abcense to my preceptors and our placement officer Teresa Avampato and also i feel i excel at
building rapport with the children and parents.
one thing i could work on is asking for guidance in creating treatment plans when i am unsure of the activities and the
relvance if the activities being performed
Final; Some things i did well on are effectivly discussing my conserns or confusion during treatment sessions and group
discussions, i am able to effectivly communincate when i am unsure of a task or when i need further explanation. i complete
my treatment plans and my written documentation soap notes on time and thouroughly
One thing i could work on would be asking for help to expand creative ideas when creating treatment plans or creativing
activities to take home
Revised March 30, 2020
Rating Scale: 5: Independent, 4: Approaching independence, 3: Acquiring independence,
2: Emerging independence, 1: Unsatisfactory
Treatment Implementation
Midterm 3
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 3.5
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 4
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). 3.5
Demonstrates critical thinking Midterm 3
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, 3.5
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 4
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, 4
Final
privacy)
Treatment Implementation Comments:
one thing i think i do well with is execution of the treatment plans once i have a solid plan, i try to ensure i get
through most of their goals and get throughevery activity
some things i can work on can be ensuring the activities i have planned are relevant to the clients goals and have
complete understanding of the fine motor delays they might present with, i find sometimes when i am unsure of
the task, my treatment plans become very unorganized and messy. i can also work on my critical thinking skills to
continue the treatment plan and come up with activities on the spot
Final; a few things i did well on would be ensuring my treatment activities have relevance and they are goal
focused and surrounded around what the child would like to achieve that treatment session, another thing i did
well on would be problem solving activities when one activity might not work out i have a back up plan.
one thing i could work on would be, my timing of the activities as i feel i have not dveloped the awareness of
when an acitivity has gone on for too long or if it has been too short, i will work on my time management in the
future to ensure i am managing the treatment session time is adequate
Revised March 30, 2020
Rating Scale: 5: Independent, 4: Approaching independence, 3: Acquiring independence,
2: Emerging independence, 1: Unsatisfactory
Organization of Service Delivery
Midterm 4
Performs non-clinical duties
Examples of Performance Indicators: Organizes and maintains equipment,
supplies, and written resources. Completes administrative tasks (e.g. workload Final 3.5
measurements, scheduling, quality improvement initiatives, inventory).
Participates in education of team members, peers, and other learners as
assigned.
Organization of Service Delivery Comments:
things i find i do well on is making sure my materials are organized before the treatment sesions begin, i complete SOAP notes on time before
the end of the day
one thing i feel i could work on is my time management i could prepair more and organize myself better so that i am not rushing so much once
the end of the treatment session is complete.
Final; one thing i think i did well on is making sure my documents are signed by both me and my preceptor before they are put in their proper
folders i also thing i have done well with ensuring all my materials are printed and organized before the kids arrive
one thing i could work on would be participation of education of my group members and sharing progress of the kids i work with
Revised March 30, 2020
Midterm Summary
Performance at Midterm:
Exemplary Satisfactory Unsatisfactory (explain below)
General Comments:
i have really enjoyed this placement so far, i feel like i am learning so much more and the
one on one time with the children and watching them grow has been so much fun. overall
there are a couple areas of improvement which i will work on directly with my preceptors to
ensure success.
Strengths:
Time management to complete treatment plans, set up and take down during clinic time.
i feel i work well independently aswell as in our small group.
efficency when completing SOAP notes at the end of the day
communication with my preceptors and my classmates regarding clinical tasks
building rapport with families and children.
Areas for growth:
Expanding my knowledge on how to effectivly adress the clients goals during the treatment sessions
confidence in performance during treatment sessions
Asking for help when i am unsure of a task.
ensuring i am throroughy prepaired in treatment sessions and having multiple activites prepaired in case there is a need
to change direction for whatever reason.
The midterm evaluation was reviewed with the student
Clinical Supervisor(s): Date
Print Name / Designation Signature
The midterm evaluation was reviewed with the clinical supervisor
Madison Hamlyn October 21, 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:
i really enjoyed this placement, i find watching the progress of the children and watching them complete their
goals is very rewarding and humbling. i am truly grateful for this opportunity to work with these kids and expand
my knowledge of documentation and treatment planning
Strengths:
- ensuring my treatment plans are sent in on time
- ensuring my soap notes and documentation is dated and signed by both me and my preceptor before putting
them in their folders
- communincation between myself, my group memebers and my preceptor when i am confusing or unsure of a
task/ when i will be absent and my plans to make up my hours
Areas for growth:
- my confidence during treatment sessions
- participation of education of my group members and sharing progress of the kids i work with
- my timing of the activities as i feel i have not dveloped the awareness of when an acitivity has gone on for too long or if it has been too
short, i will work on my time management in the future to ensure i am managing the treatment session time is adequate
Attendance: No. of days No. of days Total hours completed at placement: 188
absent: late:
Profession allocation of OTA:PTA
3 0 %: %
Reason for absence:
Positive for Covid-19
Overall Performance on this Placement:
Exemplary Satisfactory Unsatisfactory (explanation required)
Clinical Supervisor(s):
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)
Madison Hamlyn December 9, 2022
Print Name / Designation Signature Dat
Reviewed May 11, 2020
