Philadelphia Region Fieldwork Consortium
Student Evaluation Of Level I Fieldwork
Student name__________________________ Student ID# ____________________________
Site name: ____________________________ Course number:____________
Supervisor name (print)______________________ Credentials _______ Years exp _______
Semester:
Year:
Sequence:
[ 1 ] Fall
[ 10 ] 2008
[ 1 ] 1st
[ 2 ] Spring
[11] 2009
[ 2 ] 2nd
Type of setting (check primary)
Assistive Tech.
Emerging practice
Gerontology - SNF/LTC
Gerontology - other
Home health
Hand therapy
1=Strongly Disagree
2=Disagree
[ 3 ] Summer
[12] 2010
[ 3 ] 3rd
[13] 2011
[ 4 ] 4th
Phys dys – Outpatient
Phys dys – Inpatient acute
Phys dys – Inpatient rehab
Work hardening
Other:_________________
MR/DD
MH – hospital
Peds – hospital
Peds – school
Peds – other
3=Neutral
[14] 2012
[ 5 ] 5th
4=Agree
5=Strongly agree
SUPERVISION
1.
2.
3.
4.
5.
6.
7.
8.
There was a well planned FW I program
Supervisor provided adequate orientation
There were regularly scheduled feedback sessions
Supervisor effectively provided positive reinforcement
Supervisor effectively provided constructive feedback
Supervisor provided opportunities to discuss background information on patients/clients
Supervisor provided opportunities to discuss application of OT to patients/clients
Individual serving as primary supervisor 1= OTR 2= COTA 3= OT student 4= Non-OT
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
EXPERIENCE OF OCCUPATIONAL THERAPY PROCESS
11.
12.
13.
14.
There was opportunity to experience the evaluation process
There was opportunity to experience occupation-based interventions
There was opportunity to experience purposeful interventions
There was opportunity to experience preparatory methods
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
5
5
5
5
ASSIGNMENTS: Indicate the value of written assignments.
1=Worthless
2=Minimal value
3=Neutral
4= Valuable
15.
16.
17.
5= Very valuable
1 2 3 4 5
1 2 3 4 5
1 2 3 4 5
FACILITY
1=Strongly Disagree
2=Disagree
3=Neutral
4=Agree
20. The environment was conducive to learning
21. There were adequate opportunities to interface with patients/clients
22. Should there be any additions to or deletions from the FWI program?
Explain:
5=Strongly agree
1 2 3 4 5
1 2 3 4 5
[ ] Yes [ ] No
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
CLINICAL SKILLS: To what degree did you practice the following clinical skills (check ALL
that apply)?
1 = Skill not applicable to this setting
Sensory-Motor
Adaptive equipment and AD rec/training
Bathing/showering
Caregiver skills
Community re-integration
Dressing
Eating
Energy conservation training
Feeding
Functional communication skills
(writing, phone, etc)
Functional mobility
Grooming
Health management/maintenance
Home management
Oral hygiene
Play/leisure skill development
Safety / emergency training
School-related activity training
Toileting
Transfer training
Arts/crafts
Documentation
Ethics
Games
Leading groups
Therapeutic use of self
Cognitive-Psychosocial
Other
ADLs/IADLs
ADLs/IADLs
2 = participation was limited to observation
3 = experienced skill with FW supervisor, staff or other students
4 = experienced skill with actual patients/clients
Body mechanics training
Fine motor coordination training
Gross motor coord. training
Joint protection training
Motor control techniques
Motor learning interventions
NDT interventions
Neuromuscular reeducation
PNF
Positioning and handling
Sensory re-education
SI interventions
Strength and endurance training
Visual-motor training
Visual-perceptual skills training
Ability to explain OT to others
Activity sequencing training
Attention, orientation, concentration
Behavior management
Cognitive-perceptual retraining
Initiation-termination training
Problem-solving training
Social skills training
Stress management/coping skills
Time management training
What factors limit active student participation actual patients or clients in your setting?
_______________________________________________________________________________________________
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What factors facilitate active student participation with actual patients or clients in your setting?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Comments about this fieldwork experience:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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Student signature
Supervisor signature
Date
_______
 Philadelphia Region Fieldwork Consortium
Date