Canadian OTA and/or PTA Student Fieldwork

Evaluation Form

Helias Almasak
Student’s Name:

Placement ☐ Field Placement I ☐ Field Placement II

☐ Block Placement
Durham College Advisor Laura Maybury
Name:
Clinical Supervisor’s Name Greg Grierson
Clinical Supervisor’s Physiotherapist
Designation:
Campus Health Centre
Name of Facility
☐ 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).
Laura Maybury, Reg. PT (Ont.) OTA
& PTA Professor & Coordinator
Durham College, Oshawa, Ontario
laura.maybury@durhamcollege.ca

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). A how-to document will be included with
the evaluation for your reference.

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 Please contact us if you have any related questions or
concerns.

Reviewed May 26, 2017 Page 1 of 12

 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 May 26, 2017 Page 2 of 12
Rating Scale: 5: Independent, 4: Approaching independence, 3: Acquiring independence,
2: Emerging independence, 1: Unsatisfactory

Professionalism & Accountability

Midterm 3
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
within personal abilities and limitations. Seeks support / assistance
Final 4
appropriately. Asks appropriate questions. Follows supervision and
communication guidelines.
Mid-term comments
Follows instructions well. Asks a lot of questions.

Final comments
As above

Midterm 3
Takes responsibility for service components as assigned
Examples of Performance Indicators: Prioritizes assigned duties and resources
appropriately. Demonstrates effective time management skills. Final 4

Mid-term Comments
No concerns

Final comments
Much better initiative to use time effectively

Midterm
Demonstrates professional behaviors 3
Examples of Performance Indicators: Exhibits respect, initiative and enthusiasm.
Follows workplace expectations (e.g. policies and procedures, hours of work, Final
attire, hygiene, use of technology). Assumes responsibility for own actions. 4
Maintains appropriate boundaries in therapeutic and professional relationships.
Mid-term Comments
Beginning to show initiative in performing daily tasks.

Final comments
Always professional and respectful of others. Initiative and enthusiasm much imroved.

Page 3 of 12
Rating Scale: 5: Independent, 4: Approaching independence, 3: Acquiring independence,
2: Emerging independence, 1: Unsatisfactory

Professionalism & Accountability

Midterm 4
Engages in self-reflection
Examples of Performance Indicators: Identifies strengths and areas for
improvement. Accepts constructive feedback and integrates recommendations Final 4
into practice. Develops and implements learning strategies using appropriate
resources.
Mid-term comments
seems to understand his strenghts and areas for improvement

Final comments
As above

Reviewed May 26, 2017 Page 4 of 12

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

Communication & Collaboration

Midterm
Communicates in a Professional Manner 4
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
5
client and team performance (e.g. cueing, providing feedback with dignity and
empathy, listening, guiding)

Mid-term comments

Excellent communication skills. Very comfortable talking to any clients regardless of gender/rac

Final comments
Same

Uses communication skills effectively Midterm

Examples of Performance Indicators: Clearly and accurately exchanges verbal 3
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
Final
in a timely and accurate manner according to workplace expectations (e.g. 4
documenting in clients’ charts, caseload log, taking messages, emails, flow
sheets).
Mid-term comments
Verbal communication is excellent (as above). No opportunities to use written communication
in our setting.

Final comments
Good

Collaborates with Inter-professional Team Midterm 2

Examples of Performance Indicators: Recognizes roles of team members.
Participates actively as a team member to optimize client care and provide
continuity in service delivery. Consults with/reports to the appropriate team Final 2
member. Identifies and manages conflict.

Mid-term comments
We dont really have any opportunity to collaborate with other "team" members.

Final comments
Same

Reviewed May 26, 2017 Page 5 of 12

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

Treatment Implementation
Competency: Midterm
Performs assigned therapeutic interventions (direct patient care) 2
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
4
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
Treatment application is always safe. Gradually becoming more independant.

Final comments
Much better at explaining treatment to clients

Competency: Midterm
Performs assigned therapeutic interventions (indirect patient care) 4
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 4
environmental scan, follows precautions and contraindications).

Mid-term comments
Excellent

Final comments
Same

Reviewed May 26, 2017 Page 6 of 12

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

Treatment Implementation
Demonstrates critical thinking Midterm
Examples of Performance Indicators: Integrates knowledge (e.g. anatomy, 2
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,
Final 3
determines possible options, recognizes risks, implement solution, reflect and
revise). Analyzes and interprets information accurately (e.g. chart review)

Mid-term comments
Not given much opportunity to do so in our small practice. ie) is always working directly with th
e treating professional, so doesnt need to make the critical decisions.

Final comments
Ability to apply anatomy and physiology is improving

Protects the client from harm Midterm

Examples of Performance Indicators: Obtains client’s informed consent prior to 3
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,
Final 4
privacy)
Mid-term Comments
No concerns

Final comments
Good

Reviewed May 26, 2017 Page 7 of 12

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

Organization of Service Delivery

Competency: Midterm
Performs non-clinical duties 3
Examples of Performance Indicators: Organizes and maintains equipment,
supplies, and written resources. Completes administrative tasks (e.g. workload Final
measurements, scheduling, quality improvement initiatives, inventory). 4
Participates in education of team members, peers, and other learners as
assigned.
Mid-term comments
Graduallly performing more tasks independantly without prompting.

Final comments
Continueing to improve

Reviewed May 26, 2017 Page 8 of 12

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

General Comments:
Helias is doing very well. He is very attentive and asks a lot of questions.

Strengths:
Attentive. Proffesional. Learning quickly. Good communication skills.

Areas for growth:

Continue to get more independant with daily tasks. Get further practice explaining therapeauti
c benefits and reasons for treatment interventions. Continue to practice identifying anatomical
landmarks and common MSK injuries

The midterm evaluation was reviewed with the student

Clinical Supervisor(s): Date

Greg Grierson Feb.26’18
Print Name / Designation Signature

The midterm evaluation was reviewed with the clinical supervisor

Helias Almesak Feb.26'18
Student Print Name Signature

Student was well prepared for this placement. Yes No

If no, please indicate areas of insufficiency.

Comments:

Reviewed May 26, 2017 Page 9 of 12

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

General Comments:
Helias did very well. He progressively showed more initiative and became more independant,
allowing him to help us significantly by the end of his placement.

Strengths:
Excellent communication skills. Is able to comfortably talk to all staff and all types of clients. A
pplication of modalities. Attentive and not afraid to ask questions.

Areas for growth:

Continue to apply knowledge of anatomy, pathology,etc towards the understanding of assessm
ents and treatment.

Attendance: No. of days No. of days Total hours completed at placement: 150
absent: late:
Profession allocation of OTA:PTA
0 2 0 %: 100 %
Reason for absence:

Overall Performance on this Placement:

Exemplary Satisfactory Unsatisfactory (explanation required)

Clinical Supervisor(s): Date

Greg Grierson March 28, 2018
Print Name / Designation Signature

Print Name / Designation Signature

Assigning OT or PT

Print Name / Designation Signature

Print Name / Designation Signature

Student signature verifies that the evaluation was reviewed with the evaluator(s)
Helias Almasak March 28, 2018
Print Name Signature

Reviewed May 26, 2017 Page 10 of 12

 Page of

Fieldwork Attendance Form

FACILITY NAME & AREA OF PRACTICE:____________________________________________________________ STUDENT’S
NAME: _______________________________ DATES OF PLACEMENT:_____________________

Instructions for Preceptor: The student is responsible for maintaining and submitting this record. To verify that students
have attended the required hours, sign in the appropriate space each time the student attends placement.

Upon placement completion sign the bottom of the form to verify total hours completed and to confirm that the student was
successful on placement. Students are required to submit all pages of this form electronically, with hours totaled, as evidence of
ALL placement hours within 24 hours of placement completion.

Date OTA hours PTA hours Preceptor Signature & Comments

completed completed
each day each day

Total OTA Hours on Placement: _ Total PTA Hours on Placement:

Preceptor signature: Date:

Student signature: Date:

Reviewed May 26, 2017 Page 11 of 12

 Optional Feedback Form

Durham College is committed to developing OTA/PTAs that are responsive to our community’s
needs. We welcome your feedback and strive to provide a positive experience for our
community partners, clients, preceptors and students.

1) Please identify any areas of strength OR areas requiring further development with regard to
the preparedness of our students (knowledge/skills):

2) Please provide feedback regarding the placement process and your overall experience
as a preceptor in the OTA & PTA program:

3) Please any additional feedback or recommendations you would like to share:

With our kindest thanks for sharing your valuable time and expertise with our students. We
hope that this has been a positive experience and look forward to working with you in future.

Reviewed May 26, 2017 Page 12 of 12