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Flem ing Col lege


Occu pational Therapist Assistant and Physiotherapist Assista nt Prog ram

Field Experience I Evaluation Form (Two Day-a-Week Placement)

Student Name: Date: T-re-c l6th 2otta.

Agency Name: Number of Hours Completed in: Qb ora (le
Student Preceptor: E\q.. t-**l'' \eo-r\n
Number of Days sick or absent: 6 Times late: Q

Fieldwork experiences are critical to student development as they provide students the opportunity to acquire essential
skills and competencies required to function as an effective member of the health care team. ln 3'd semester the
students participate one introductory clinical experience, completing two days a week for 7 weeks. They are working
towards achieving the program standard of 540 clinical hours, with no less than 30% of the total hours being in one

lfi Field Experience l, the student is, for the first time, seeing their acquired academic knowledge and practical skills '
occurring in a 'real' therapeutic setting. Under the direct supervision of the clinical supervisor, the student is active in
appropriate interventions as an OTA & PTA. They may also observe competencies rather than directly engaging in task
performance. The student develops awareness of interpersonal skills, application of techniques hnd equipment. Please
refer to the 'Clinical Skills lnventory' for additional information.

ln this course, Field Experience l, our expectation is that the student should be performing, as the minimum standard,
in the 'working towards'column by the end of this placement.

All fieldwork experiences should reflect a cooperative working relationship between the OT or PT and the OTA and PTA.
It is therefore, appropriate for the OTA or PTA to participate in the supervision of the student during their fieldwork
experience and to participate in or fully complete the evaluation form. The Registered OT or PT who delegates tasks to
the Assistant and/or student needs to co-sign the evaluation form'

please check the selected letter beside each line. The option of a midterm evaluation is left to the discretion of the
supervising therapist but ongoing, informal feedback should be sought by and provided to the student.

(please note: lnsert N/A if there has been no opportunity to evaluate this aspect of the student's competency.)
ffi a flag beside a performance criterion indicates a "red-flag" item. These items bre considered key elements in clinical
performance. Difficulty with one of these items requires immediate attention and may include remediation and/or
dismissal from the clinical experience. Please contact Fleming faculty should these items be flagged at midterm.

Rating Scale: U= UnsatisfactorY W = WorkingTowards

M = Meets Expectations E = Exceeds Expectations

Note: Evaluations are due on or the day after the final day of placement.
Fleming College

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f . zuage in effective, respectful verbal and nonverbal communication with
the client, preceptor and intra- professional team members.

2. Produce accurate, objective, and precise written and electronic

communication e.g. health records, patient hand-outs

f . Support diversity in communication by using professional, appropriate

language, strategies and materials. v
;m"t"rt -"vant and accurate information to staff and client in a
timelv, efficient manner.
s. Use phone, computers and other technological tools with ease and
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efficiency. (

Ptease provide examples/comments of the above:

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1. Demonstrate trust, integrity, commitment, respect and compassion in all

orofessional relationshiPs.
2. Understand and demonstrate respect for the different roles of
rehabilitation team members. x
3. ilkaAf,"r" to legislation and facility guidelines regarding the protection of
privacy, security of information etc. in order to protect client, family and x
orga nizationa I confidentiality.

4. ffiOU,rtn client's permission to proceed prior to performing assigned

5. ffi*r,n,",n personal and professional boundaries. a x
6. Perform within the limits of personal competence and identify and
communicate to his/her supervisor when a client's needs exceed the limits x
of his/her knowledge, skill, or judgment.
7. Seek out learning opportunities in order to improve knowledge and
oerformance i.e. demonstrated initiative $ h
8. Manage his/her time effectively.

9. Take responsibility for his/her actions in the work environment.

10. Dress and behave appropriately to the work environment.
11. Arrive promptly and give proper notice of lateness or absence.
12. Practice self-reflection in order to improve performance.

Please provide examples/comments of the above:

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Fleming College

3.1 Practice Process

3.1.1 Demonstrate an understanding of client centered practice.
*., ffi remonstrate personal safety and the safety of others at all times.
3.1.3 Gather qualitative and quantitative information and data related to the
client's status as assigned by the supervising OT/OTA or PT/PTA- x
3.1.4 Demonstrate effective problem solving, judgment and critical thinking
skills. x
3.1.5 Contribute, where appropriate and with supervision, to the
development, implementation and modification of client care plans. x
It.O Contribute, as required, to the effective and efficient operation of the
practice settingle.g. cleaning equipment, ordering supplies, taking x
inventory, etc.
3.2 Effective Practitioner
Safely and competently, with the appropriate level of supervision,
perform assigned tasks with clients including (but not limited to) use of: x
o specific exercise equipment (e.g. bike, treadmill, pulleys, weights, etc.)
. modalities (e.g. heat, cold, ultrasound, traction, lFC, etc.)
. measuring instruments (goniometer, strength testing, functional abilities
testin& etc.)
o functional mobility training (transfer techniques with/without
equipment, bed mobility, gait training, wheelchair training, etc.)
o selected use of exercise programs (ROM, stretching, strengthening ,
conditioning, etc.)
o education and training of clients and their significant others re:
techniques, use of equipment, exercises, cognitive retraining, sensory,
leisure or ADL activities
o ADL training
o assistive devices, aids and technology training
o perceptual and cognitive retraining
o leisure activities
. Others specific to placement setting

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Fleming Col lege

Precepto/s Comments:

Student's Comments:
Was the orientation to the org'anization's policies and procedures adequate?

*Student Signature

Assistant's Signature (if applicable)

signatur" fj2,,.l.j) Rs ^^t C

*supervising or or PT's

*must be included prior to submitting to Fleming College

Pleose emoil or fqx the completed evoluation form to:

Jeanette Boersma
jeanette.boersma@flemi ngcollege.ca
tf preferred, the evaluation form can.be returned by the student in a sealed envelope with the signature of the
supervisor written across the seal of the envelope.