The Pennsylvania State University Associate in Science in Occupational Therapy Evaluation of Level I Fieldwork Experience: OT 195A Student’s name_______________________________________________________________________________ Dates Attended/Hours completed________________________________________________________________ Site_____________________________________________________Phone_______________________________ Fieldwork Educator__________________________Credentials___________E-mail_________________________ Address______________________________________________________________________________________ Grading: Please check appropriate box that best describes student performance Standard Punctual Does Not Meet (0) *Late for beginning of day *Late for assigned treatment sessions and/or meetings Evaluator Student Appearance Ethical Behavior Exceeds (2) Greatly Exceeds (3) *On time for beginning of each day and all assigned treatment sessions and/or meetings Evaluator Student *Poor hygiene *Inappropriate body adornment *Clothing inappropriate for task Evaluator Student *Breaks Code of Ethics *Does not comply with learned HIPPA regulation *Good hygiene *Clothing appropriate for task *Discreet body adornment Evaluator Student *Behavior generally reflects Code of ethics *Complies with HIPPA regulations Evaluator Student *Needs prompting Evaluator Student *Does what is expected *Seeks opportunity to participate in the session per supervision Evaluator Student *Verbal/nonverbal communication negatively impacts fieldwork experience Evaluator Student *Verbal/nonverbal communication adequate for fieldwork experience Initiative Communication Skills Meets (1) *Demonstrates an applied understanding of Code of Ethics *Consistently complies with HIPPA regulations Evaluator Student *Occasionally does more than expected *Seeks out new learning experiences with some prompting from supervisor Evaluator Student *Verbal/nonverbal communication skills are a strength Evaluator Evaluator Evaluator Student Student Student *Consistently demonstrates a depth of understanding of ethical behavior in a broad variety of situations Evaluator Student *Independently seeks out new learning experiences *Consistently does more than expected Evaluator Student *Verbal/nrnverbal communication skills significantly beyond entry level practitioner Evaluator Student Standard Safety Awareness Does Not Meet (0) Meets (1) *Engages in unsafe behavior putting self and others at risk *Behaves in compliance with basic safety requirements for self and others *Follows agency infectious control standards, with one verbal prompt Evaluator Evaluator Student Interpersonal Skills *Does not make eye contact *Does not respond to questions from supervisor Evaluator Student Student *Listens to client *Listens to supervisor *Responds to questions from client and supervisor *Converse with client on a non-therapeutic level Evaluator Student Student Evaluation Exceeds (2) Greatly Exceeds (3) *Verbalizes needs of safety for self and others *Demonstrates good body mechanics *Consistently follows agency infectious control standards Evaluator Student *Interacts with clients and participates verbally in treatment sessions as appropriate *Interacts with supervisor both initiating conversation and responding appropriately regarding clinical process Evaluator Student *Interacts appropriately with staff, client’s families, and other healthcare professionals *Is able to therapeutically use self as a treatment modality Evaluator Student FW Educator Evaluation TOTAL SCORE: A score of 6 or above is passing. A score of 5 or below is failing. A zero (0) in safety awareness and/or ethical behavior is an automatic failure. Student comments: Fieldwork Educator comments: Fieldwork Educator Signature:____________________________________________________Date:__________________________ Student Signature:____________________________________________________Date:___________________________