The Pennsylvania State University
Associate in Science in Occupational Therapy
Evaluation of Level I Fieldwork Experience: OT 195B
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
Standard
Exceeds (2)
Student
*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
*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
Does Not Meet (0)
*Engages in unsafe
Greatly Exceeds (3)
*On time for beginning
of each day and all
assigned treatment
sessions and/or
meetings
Evaluator
*Poor hygiene
*Inappropriate body
adornment
*Clothing inappropriate
for task
Evaluator
Student
*Breaks Code of Ethics
*Does not comply with
learned HIPPA
regulation
Initiative
Communication
Skills
Meets (1)
Meets (1)
*Behaves in compliance
Exceeds (2)
*Verbalizes needs of
*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
Greatly Exceeds (3)
Safety
Awareness
behavior putting self and
others at risk
Evaluator
Evaluator
Student
Interpersonal
Skills
Problem
Solving
with basic safety
requirements for self
and others
*Follows agency
infectious control
standards, with one
verbal prompt
Student
*Does not make eye
contact
*Does not respond to
questions from
supervisor
*Listens to client
*Listens to supervisor
*Responds to questions
from client and
supervisor
*Converse with client on
a non-therapeutic level
Evaluator
Student
*Asks unnecessary
questions
*Needs supervisor to
suggest solutions
Evaluator
Student
*Asks questions about
current situations (client
or intervention sessions)
*Answers supervisor’s
questions that draw on
previous knowledge
Evaluator
Student
Evaluator
Student
Student Evaluation
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
*Initiates questions and
ideas with supervisor
*Reasons with new and
previously acquired
information
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
*Synthesizes
information before
forming questions
*Uses information in
different contexts to
create solutions
Evaluator
Student
FW Educator Evaluation
TOTAL SCORE:
A score of 7 or above is passing. A score of 6 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:___________________________