Canadian OTA and/or PTA Student Fieldwork

Evaluation Form
Student’s Name: Ashleigh Cole

Placement ☐ Field Placement I ☐ Field Placement II

☐ Block Placement
Durham College Advisor
Name:
Clinical Supervisor’s Name
Clinical Supervisor’s
Designation:
Taunton Mills
Name of Facility
☐OTA
Discipline Focused on ☐PTA
During Placement: ☐OTA & PTA
Ratio OTA:PTA %
Facility Setting: ☐Acute care ☐Rehabilitation ☐Long Term Care
☐Day Hospital ☐Community ☐Out-patient clinic
☐Other:
Client Population Check ☐Paediatric ☐Adult ☐Geriatric ☐Other:
all that apply
☐MSK ☐Mental Health ☐Respiratory ☐Endocrine
Client Category
☐Neuro ☐Cardiac ☐Oncology ☐Transplant ☐Multiple
Check all that apply
Systems ☐Other:
Submission of the Preceptor’s evaluation form to the Program Coordinators

Via email (word and PDF versions of the form are available).
Teresa Avvampato, OT Reg.(Ont.)
OTA & PTA Professor & Coordinator Durham
College, Oshawa, Ontario
teresa.avvampato@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 clientcentered
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.
Approaching Student can perform the competency/skill with occasional (minimal)
4 independence guidance, support, and/or direction from Clinical Supervisor (OTA/OT
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.

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

Professionalism & Accountability

Midterm 3

Practices within scope of professional parameters and personal abilities

Examples of Performance Indicators: Performs within the scope of the OTA
Final 4
and/or PTA role. Works within their role as a therapist assistant student and
within personal abilities and limitations. Seeks support / assistance
appropriately. Asks appropriate questions. Follows supervision and
communication guidelines.
Mid-term comments: I always perform within the scope of OTA/PTA, and I always ask questions
whenever I am uncertain about something, and always follow the OT’s protocol and
suggestion.

Final comments I always perform within the scope of OTA/PTA, and I always ask questions
whenever I am uncertain about something, and always follow the OT’s protocol and
suggestion

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

Mid-term Comments: I have handed in all requirements, aside from handing my TB test result to
Taunton Mills late. I have handed in all assignments on time, as well as my weekly checklists.

Final comments I have handed in very few assignments in late. I always hand in my weekly checklists
on time, even during the strike. I am always early to placement and have never missed a full day.

Midterm 3

Demonstrates professional behaviors

Examples of Performance Indicators: Exhibits respect, initiative and enthusiasm.
Final 4
Follows workplace expectations (e.g. policies and procedures, hours of work,
attire, hygiene, use of technology). Assumes responsibility for own actions.
Maintains appropriate boundaries in therapeutic and professional relationships.
 Mid-term Comments: I always present with professional behaviours, and attire. I follow
workplace expectations, and do everything that is required of me. I maintain professional
relationships with other peers, residents, and workers.

Final comments I always present with professional behaviours, and attire. I follow workplace expectations, and do
everything that is required of me. I maintain professional relationships with other peers, residents, and workers.

Page 3 of 12

Reviewed May 26, 2017 Page 4 of 12

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

Professionalism & Accountability

3
Midterm
Engages in self-reflection
Examples of Performance Indicators: Identifies strengths and areas for Final 4
improvement. Accepts constructive feedback and integrates recommendations
into practice. Develops and implements learning strategies using appropriate
resources.
Mid-term comments: I learn and do research on different strategies for her OT sessions, and
different interventions that may help her, and discussing those ideas with the OT. I am always
open to help from both the OT and peers as well. I can identify few strengths and areas for
improvement. I often spend off hour time focussing on interventions and reflecting on
previous days of placement.

Final comments I learn and do research on different strategies for her OT sessions, and different interventions that
may help her, and discussing those ideas with the OT. I am always open to help from both the OT and peers as
well. I can identify few strengths and areas for improvement. I often spend off hour time focussing on
interventions and reflecting on previous days of placement.

Reviewed May 26, 2017 Page 5 of 12

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 Final 4.5
(e.g. considering education, culture, age and gender). Promotes optimal client
and team performance (e.g. cueing, providing feedback with dignity and
empathy, listening, guiding)
Mid-term comments: I was able to establish rapport with my resident, OT, and other workers.
When we do “friendly visits” I have to be able to build a rapport very quickly, with some who
may have language barriers or hearing impairments.

Final comments I was able to establish rapport with my resident, OT, and other workers. When
we do “friendly visits” I have to be able to build a rapport very quickly, with some who may
have language barriers or hearing impairments.

Uses communication skills effectively Midterm 3

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 Final 4.5
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: I have to be able to watch body language and non verbal communication
to observe my resident and see how they are tolerating treatment. I have to use appropriate
written communication for SOAP note documentation, and email correspondence with
preceptor.

Final comments I have to be able to watch body language and non verbal communication to
observe my resident and see how they are tolerating treatment. I have to use appropriate
written communication for SOAP note documentation, and email correspondence with
preceptor.

Collaborates with Inter-professional Team 4

Midterm
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 4.5
Final
member. Identifies and manages conflict.
Mid-term comments: Taunton Mills has a wide variety of professions such as OT’s, PTA’s
Kinesiologist’s, PSW’s, and nurses. I have to be able to communicate with them and work
together as a team.

Reviewed May 26, 2017 Page 6 of 12

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

Final comments
Taunton Mills has a wide variety of professions such as OT’s, PTA’s Kinesiologist’s, PSW’s, and nurses. I have to be able to
communicate with them and work together as a team. Working at the Christmas market and also doing the dementia with the
interprofessional team

Treatment Implementation
Competency: 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. Final 4.5
Participates in client education. Implements therapeutic intervention using a
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 I am able to create and facilitate my own OT interventions with my
designated resident. With every therapy session I receive consent and with that I explain the
risks and benefits. I reflect on the clients response to treatment and discuss this with the OT. I
aways close of the session, reminding them of when the next session will be, and what to
expect. I always talk about the session with the OT, and do the proper documentation.

Final comments I am able to create and facilitate my own OT interventions with my designated
resident. With every therapy session I receive consent and with that I explain the risks and
benefits. I reflect on the clients response to treatment and discuss this with the OT. I aways
close of the session, reminding them of when the next session will be, and what to expect. I
always talk about the session with the OT, and do the proper documentation.

Competency: Midterm 3
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 4
environmental scan, follows precautions and contraindications).

Mid-term comments: I always come prepared with whatever equipment I may need for my
therapy session, and have a plan in place for the intervention. I always make sure the
environment is safe to perform the session, and respect her abilities and limitations
throughout the session.

Reviewed May 26, 2017 Page 7 of 12

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

Final comments I always come prepared with whatever equipment I may need for my therapy session, and have a
plan in place for the intervention. I always make sure the environment is safe to perform the session, and respect
her abilities and limitations throughout the session.

Treatment Implementation
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, Final 3.5
determines possible options, recognizes risks, implement solution, reflect and
revise). Analyzes and interprets information accurately (e.g. chart review)

Mid-term comments: I have been doing research on sensory stimulation and how to integrate it
into our therapy sessions. I problem solve when I may not have the equipment I wanted for
the intervention. I review and reflect on how the session went and how I can change and
improve.

Final comments When my resident may not like the intervention I have planned I have had to think on
my feet to create a new plan. I have had to come up with creative ways to do the same goal but in
different ways to keep the resident engaged. I review and reflect on how the session went and
how I can change and improve.

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. Final 4
safe use of equipment, infection control, correct handling techniques, draping,
privacy)
Mid-term Comments: I always make sure the resident is feeling up to doing therapy that day, and
continually ask the resident about pain and continue consent throughout entire session.

Reviewed May 26, 2017 Page 8 of 12

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

Final comments
I always make sure the resident is feeling up to doing therapy that day, and continually ask the resident about pain and
continue consent throughout entire session.

Organization of Service Delivery

Competency: Midterm 3
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.
Mid-term comments: I am always an active participant in group discussions and try to learn
from the other student’s experiences. I actively try to learn not just from the OT, but also the
PTA, as well as the kinesiologists.

Final comments I am always an active participant in group discussions and try to learn from the other student’s
experiences. I actively try to learn not just from the OT, but also the PTA, as well as the kinesiologists.

Reviewed May 26, 2017 Page 9 of 12

Midterm Summary
Performance at Midterm:
Exemplary Satisfactory Unsatisfactory (explain below)
General Comments: I am enjoying placement more then I thought I would initially. I am working very
hard to come up with creative interventions for my resident.

Strengths: Being creative in my ideas, gaining strong rapport with residents. Having a positive and
optimistic attitude.

Areas for growth: being more confident in myself, critical thinking, and self reflection.

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:

26, 201 Page 9

Reviewed May 7 of 12
Final Summary of Evaluation of Clinical Competencies
To be completed at the end of the placement only.

General Comments: overall enjoyed my placement, I think my eyes have been opened up to a field in
long term care

Strengths: building rapport with residents, being creative and engaging in therapy sessions.

Areas for growth: confidence, and leadership

Attendance: No. of days No. of days late: Total hours completed at placement: 200
absent:
0 1 Profession allocation of OTA:PTA
__100_%:__0_%
Reason for absence: program meeting

Overall Performance on this Placement:

Exemplary Satisfactory Unsatisfactory (explanation required)

Clinical Supervisor(s): Date

______________________
Print Name / Designation
______________________
Print Name / Designation
Assigning OT or PT
______________________
Print Name / Designation
_____________________
______________________
Signature
_____________________
______________________
Signature
_____________________
______________________
Signature

______________________ _____________________
Print Name / Designation ______________________
Signature
Student signature verifies that the evaluation was reviewed with the evaluator(s)

______________________ ______________________ _____________________

Print Name Signature

Reviewed May 26, 2017 Page 11 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 Preceptor Signature & Comments

OTA hours PTA hours
completed completed
each day each day

Reviewed May 26, 2017 Page 12 of 12

Total OTA Hours on Placement: ___________ Total PTA Hours on Placement: ___________

Preceptor signature: _______________________________ Date: _________________________________ Student

signature: _________________________________ Date: _________________________________

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:

Reviewed May 26, 2017 Page 13 of 12

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 14 of 12