Canadian OTA and/or PTA Student

2021-2022 Fieldwork Evaluation Form

Vladyslav Martynchyuk
Student’s Name:

Placement □ Field Placement I ☐ Field Placement II

□ Block Placement
Durham College Advisor
Name: Laura Maybury
Clinical Supervisor’s Name
Alex Giambagno
Clinical Supervisor’s
Designation: 1105 Kingston Rd. E., Unit 11
Name of Facility MedRehab Group Inc
☐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 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 4
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 4
Final
into practice. Develops and implements learning strategies using appropriate
resources.
Professionalism & Accountability Comments:
I try to meet all the requirements of a virtuous student, I am not late, I follow the treatment, and
I do not interfere with it. I help if I am asked, and I try not to inconvenience.

In the final stage of the placement, I meet all the requirements: not late, follow the treatment
and don't interfere with it. Try to be helpful and not inconvenience

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 3
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 3
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:
I got in touch with all the team members. This was easy to do because they are all very nice
people. They give advice and are understanding if something doesn't work out.

In the final stage of the placement, I keep a good relationship with the clinic members. I'm
keeping get advice for them, and they're very nice to me

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
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). 4
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
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:

I still have difficulty with the independant treatment and deadlines, but I can find solutions to
problems if necessary. I follow the accompanying measures during treatment and follow the
patients.

In the final stage of the placement, I began to feel more confident working with the equipment
and communicating with customers, but I still needed support and advice on some questions.

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 4
measurements, scheduling, quality improvement initiatives, inventory).
Participates in education of team members, peers, and other learners as
assigned.
Organization of Service Delivery Comments:
I prepare equipment and rooms for patients, connect and disconnect equipment myself.

In the final stage of placement, I do it more confidently

Revised March 30, 2020

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

General Comments:
Some areas require improvement and improve slowly during the placement; some areas
are getting better faster. I feel progress because of the help of employees. I also became
more confident with patients, and now there is no such stress as before.

Strengths:
I would call the strengths of this communication with the patients. I try to find an approach
to each of them.

Areas for growth:

I need to improve my skills in demonstrating exercises and anatomy.

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

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 feel more confident in all the activities I have done during my placement. I understood how
this happens that each client is individual and needs a personal approach. Staff also play an
essential role in the work atmosphere.
Strengths:
I would call this communication with patients. Not all patients are open people, but I always try
to be nice and polite to them.

Areas for growth:

I need to increase my knowledge in the field of exercises, learn more ways to work on this or
that part of the body and improve my understanding of anatomy

Attendance: No. of days No. of days Total hours completed at placement: 152

absent: late:
Profession allocation of OTA:PTA
%: %
Reason for absence:

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)

Print Name / Designation Signature Dat

Reviewed May 11, 2020