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:___________________________