Occupational Therapy Assistant Program
Level I Fieldwork Evaluation
Student: ____________________________________________
Date: _____/_____/______
Dates of Placement:
From: ________/________/________
To: ________/________/________
Fieldwork Setting:
Facility:_______________________________________________
_____________________________________________________________________________________
Address: _________________________________________________________________________
____________________________________________________________________________________
City: ______________________________________________________________________________
Fieldwork Educator Name: _______________________________________________________
Level I Fieldwork: (check one)
☐ Level I Fieldwork A: Integration and Practice Applications – OCTH 1019
Midterm Date_____________________
Score ___________________
Final
Date_____________________ Score ___________________
☐Level I Fieldwork B: Integration and Practice Applications – OCTH 1029
Midterm Date_____________________ Score ___________________
Final
Date_____________________ Score ___________________
☐Level I Fieldwork C: Integration and Practice Applications – OCTH 1039
Midterm Date______________________ Score ___________________
Final
Date_____________________ Score ___________________
_____________________________________
Fieldwork Educator Signature
_______________________________________
OTA Student Signature
Fieldwork Educator Summary:
Midterm
Final
OTA Student Summary:
Midterm
Final
Please complete evaluation at Midterm and Final. The OTA student must complete self-assessment and discuss with supervisor at
midterm and final.
Please return signed copies of all documents to Karen Kowalski, Academic Fieldwork Coordinator.
Score the UMDNJ Level I Evaluation using the criteria below and include to support rating:
4 = Exceeds Standards: Performance is skilled and self-initiated. This rating is rarely
given and would represent the top 5% for Level I students.
3 = Meets Standards: Performance is consistent and meets the standards for this Level
fieldwork. This rating is given infrequently at midterm and is considered a strong
final rating.
2 = Needs Improvement: Performance is progressing but l needs improvement.
This is a realistic rating of performance at midterm, and some ratings of 2
may be reasonable at final.
1 = Unsatisfactory: Performance is below standards for a Level I student and
requires significant development. This rating is given when there is a concern
about performance at midterm or when the student is unable to meet requirements
by the final evaluation.
PASSING SCORE AT MIDTERM
PASSING SCORE AT FINAL
22 points
34 points
I.
Becoming an OTA Professional
The OTA Student:
1. Attends all fieldwork sessions, is prompt, and participates in learning activities.
4321
2. Adheres to policies and procedures of fieldwork site.
4321
3. Uses sound judgment in regard to safety of health and others.
4321
4. Participates in the supervisory process by giving, receiving, and responding to questions and feedback and seeking guidance
as necessary.
4321
5. Effectively interacts with client and family or identified caregiver in a professional and therapeutic manner.
4321
6. Effectively interacts with supervisor, colleagues, and other care providers. 4 3 2 1
7. Uses language from OT Practice and medical terminology effectively.
4321
II.
Occupational Beings Across the Lifespan
The OTA Student:
8. Gathers client information from the medical/educational record, client/family
interview, and from other professionals, records appropriately, and discusses
with supervisor.
4321
9. Describes a client’s occupational performance using the terminology of the
OT Practice Framework- II.
4321
10. Gathers information to help determine a client’s occupational profile and describes the meaning and benefits of occupation
for the client.
4321
III.
Adaptation
The OTA Student:
11. Describes the effects of physical and mental health, diseases, disability and traumatic injury to the individual on occupational
performance and participation.
4321
IV.
OT Practice
The OTA Student:
12. Describes the practice setting including the state and federal policies and regulations that impact OT practice in this setting.
4321