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 22 points

PASSING SCORE AT FINAL 34 points

I.  Becoming an OTA Professional

The OTA Student:

1.  Attends all fieldwork sessions, is prompt, and participates in learning activities. 4 3 2 1

2.  Adheres to policies and procedures of fieldwork site. 4 3 2 1

3.  Uses sound judgment in regard to safety of health and others. 4 3 2 1

4.  Participates in the supervisory process by giving, receiving, and responding to questions and feedback and seeking guidance as necessary. 4 3 2 1

5.  Effectively interacts with client and family or identified caregiver in a professional and therapeutic manner. 4 3 2 1

6.  Effectively interacts with supervisor, colleagues, and other care providers. 4 3 2 1

7.  Uses language from OT Practice and medical terminology effectively. 4 3 2 1

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. 4 3 2 1

9.  Describes a client’s occupational performance using the terminology of the
OT Practice Framework- II. 4 3 2 1

10.  Gathers information to help determine a client’s occupational profile and describes the meaning and benefits of occupation for the client. 4 3 2 1

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.

4 3 2 1

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. 4 3 2 1