UNC Division of Occupational Therapy and Occupational Science
LEVEL II FIELDWORK
Midterm Feedback from Student to Supervisor
Instructions: This form is intended to prompt discussion, appreciation and problem solving. It is
to be completed prior to the midterm evaluation and can be used at any time during fieldwork.
Student: __________________________Supervisor: ________________________
Site: _______________________________ Date: ____________________
1. Orientation to site: Did your orientation provide the information you need?
[ ]Yes
[ ]Somewhat, [ ]No. List further orientation needs:
Expectations: Do you understand expectations in the following areas? (if no, explain)
2. Fundamentals (ethics, judgment, safety)
3. Tenets of OT (values, roles, collaboration)
4. Evaluation and screening
5. Intervention
6. Management (goals, costs, volume of work, supervisory relationships)
7. Communication (documentation, reporting, etc)
8. Professional behaviors (management of time, self, relationships, responsibility)
Supervision ( explain any concerns)
9. What is going well about the supervisory process?
10. What would you like to change about the supervisory process?
11. How often does supervision occur? Is this sufficient?
12. Is the type of supervision you are getting what you need to guide your work?
13. Is your supervisor encouraging you to seek out information on your own?
14. Are you being challenged to try out new things and think in new ways?
15. Is the feedback you are getting consistent? timely? Constructive? Clear?
16. Are you giving sufficient information and effort to your supervisor about your ideas,
questions, needs and concerns?
17. How can you better participate in the supervisory process?
18. How could the supervisors’ approach, style, content or timing help you learn better?
19. What factors in the fieldwork or the environment are contributing to your success?
20. What factors in the setting/environment are problematic for you?
21. Have you had any situations in which you felt unprepared to perform?
Professional Development
22. What do you feel you are doing well?
23. What do you see as the areas you need to improve?
24. Describe a particularly difficult or stressful incident in your FW experience.
25. Describe a particularly satisfying experience you have had in fieldwork so far.
26. Is the fieldwork overall meeting your expectations?(explain)
27. Are there other goals or issues you’d like to discuss with your supervisor?