UTS: ORTHOPTICS

CLINICAL SUPERVISOR ASSESSMENT AND FEEDBACK FORM

ORTHOPTICS CLINICAL PLACEMENTS PP1

To be completed at the conclusion of each student’s placement. Please use only ONE form per student irrespective of number of days attending clinic.

Student’s Name: Click here to enter text.______

Dates placement attended: Click here to enter text.______

Clinical Supervisor: Click here to enter text.______Placement Site: Click here to enter text.______

EFFECTIVE PROFESSIONAL & COMMUNICATION BEHAVIOUR – Written and Verbal / YES
Please circle / NO
Pleasecircle / OVERALL RATING AND COMMENTS
Please circle one
  • Develops rapport and is able to interact with patients and staff
  • Demonstrates professional, respectful and courteous behaviour with patients and staff
  • Is punctual and Presentation is neat and tidy
  • Student demonstrates initiative in seeking experience and offering assistance
  • Student freely presents learning goals and asks respectfully for help to achieve them
  • Students demonstrates active learning within an observational environment (asks relevant questions about assessment technique, results or patient management)
  • Student is respectful of patient confidentiality
  • If given the opportunity - Demonstrates the ability to adapt communication skills toward patients if required including the tone and language used toward the patients
/ Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes / No
No
No
No
No
No
No
No / Still to achieve / achieving / highly achieving
☐ ☐ ☐
Comments:Click here to enter text.
Evidence of KNOWLEDGE and CLINICAL COMPETENCE / YES
Please circle / NO
Please circle / OVERALL RATING AND COMMENTS
Please circle one
  • Through verbal responses the student demonstrates at minimum a sound understanding of non-complex ocular conditions discussed while on placement.
  • Are they able to begin to formulate a diagnosis from the patients symptoms
( you may need to sit down and ask the student to hypothesis what the diagnosis may be on a patient that you have jointly assessed)
  • Is the student able to suggest or discuss appropriate management options when asked
/ Yes
Yes
Yes / No
No
No / Still to achieve / achieving / highly achieving
☐ ☐ ☐
CommentsClick here to enter text.
If given the opportunity does the student:
  • Provide the patient with clear and concise testing instructions
  • Demonstrate the ability to work efficiently
  • Under supervision perform safe and sound technique when assessing a patients VA, History, CT, OM, VF, OCT or other
  • Correctly documents any findings about a patients assessment
  • Are there any particulate areas that you feel this student needs further work on
/ Yes
Yes
Yes
Yes
Yes / No
No
No
No
No / Still to achieve / achieving / highly achieving
☐ ☐ ☐
Comments:Click here to enter text.
Overall assessment of student performance while on clinical placement
1 = performs unacceptably
Showed Inappropriate & unprofessional behaviour and communication toward staff and or patients
2 = performs marginally
Showed Limited understanding of conditions, test procedure and results, but a willingness to seek the answer and provide a valid response. The students manner and ability to interact with patients’was awkward and needs improvement / 3 = performs adequately
Showed acceptable understandingof conditions, test procedures & results, student manner and interactions with patients was acceptable for a first placement
4 = performs proficiently
Showed Consistent & good understandingof conditions seen, test procedure & results obtained. Manner and patient interaction demonstrated by student was excellent / Please rate the student by ticking one box
☐ 1 ☐ 2 ☐ 3 ☐ 4
Comments:Click here to enter text.

Please return this completed feedback form attention to:Orthoptics Clinical Education via email