University of North Florida
Doctor of Physical Therapy Program
Practicum Evaluation
Student Name: ____________________________________________ Date: _______________________________________________
Site Name: ________________________________________________ CI Name: ___________________________________________
Type of Rotation: _______Acute Care
_______Outpatient
_______Rehab/Sub-Acute/SNF
______ Other (please describe) ______________________________________________________
I.
On the first day of the clinical practicum, provide your clinical instructor (CI) with the
evaluation form and review it.
II. After the twelfth visit, complete a self-assessment by marking the appropriate box in Table 1
below. Then comment on your performance for Table 2, 3, and 4.
III. Ask your CI to also complete the form and schedule a time before or during your fourteenth
visit to meet and review the form.
Table 1: Practicum Activities: Please indicate which activities student observed, assisted with,
or performed.
Activity
Bed Mobility
Observed
Participated/Assisted
Performed
Transfers/Transfer Training
Therapeutic Exercise
ROM Measurements
MMT Skills
Gait Assessment/Training
Review Medical Record/Chart
Taking Vital Signs
Wheelchair Management
Balance Assessment
Modalities
Patient Education
Manual Therapy
Patient Examination/Evaluation
Revised December 2014
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Table 2: Performance Areas: Please comment on the student’s performance for the following
practice areas.
Practice Area
Interacting/Communicating with CI or
other therapists
CI’s Assessment
Student’s Self -Assessment
Interacting/Communicating with
patients
Use of modalities
Gait training
Assisting patients with therapeutic
exercise
Assessment skills (Goniometry, MMT,
etc.)
Identification of relevant information
from medical records
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Table 3: Professionalism
CI’s Assessment
Student’s Self-Assessment
1. Student physical therapist
maintains confidentiality.
2. Student physical therapist
is reliable.
3. Student physical therapist
ensures patient safety
during care.
SD = Strongly Disagree
D = Disagree
N = Neutral
A = Agree
SA = Strongly Agree
Table 4: Assessment of areas for improvement
CI & Student: Please comment on which areas or activities need improvement.
Student: Specifically comment on any experience you had during your Practicum that contributed to this
self-assessment.
Transfers
Gait Training
MMT Skills
ROM/Goniometric
Measurements
Therapeutic Exercise
Interventions for Specific
Pathologies
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Modalities
General Hands on Skills
Time Management/Efficiency
Documentation
Patient Interview and
Examination Technique
Interaction with patients and
making them comfortable
Communication with CI, other
therapists
Identification of relevant info
from medical records
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