“@of] SANTA ANA COLLEGE Occupational Theropy Assistant Level I Fieldwork Performance Evaluation Form ‘Student Name: Danielle Ruiz Facility Name: Interface Rehab Fieldwork Dates: 10/02/23-10/30/23 # of FW hours: 32 hours Supervisor Name: Julie Bergh Supervisor Title: Regional Mentor OTRIL The purpose of Level | fieldwork is to provide experiential opportunities for students to gain the performance competency and confidence for progressing successfully in the academic program, including successive Level | and Level Il fieldwork. The Level | Fieldwork Performance Evaluation complements the AOTA Fieldwork Performance Evaluation for the OTA Student. This form has been adapted and designed to assess performance skills that build a foundation for successful completion of Level Il fieldwork. Directions This tool is to be completed by the identified supervisor or fieldwork educator and reviewed with the student at the end of the Level I fieldwork experience. Signature is required. The student will return the form to the Academic Fieldwork Coordinator. A total score of 36 or higher is required to receive a Pass grade for Level I fieldwork. Please indicate the student's performance on each item using the rating scale below: 1] Unacceptable _| Performance is weak in most required tasks and activities. Work is frequently unacceptable. 2 | BelowStandards _ | Opportunities for improvement exist, however, student has not demonstrated adequate response to feedback. Performance is occasionally unacceptable. 3| Meets Standards | Carries out required tasks and activities. This rating represents good, solid performance and should be used most often. @ | Exceeds Standards | Frequently carries out tasks and activities that surpass requirements. At times, performance is exceptional 1 Ethics: 10 20384 Follows ethical standards of FW setting. Respects privacy of client. o 2 Safety: 10 20364 Uses sounds judgement. Demonstrates awareness of potential hazardous situations. o 3. Values and beliefs of occupational therapy: 1020384 Verbalizes definition of occupational therapy as relevant to fieldwork setting or audience. o 4, Evaluation Process: 10 20384 Obtains information about factors that support and hinder client's occupational performance | from relevant sources (chart review, observations, interviews, assessments) 5. Gient centered and occupation-based interventions: 1020384 Selects and participates in activities that motivate and challenge the client to achieve Oo established goals; includes the consideration of all cient centered components. 6. Initiative: 10 2030 48 | Takes initiative, assists staff in tasks, assists with set-up and clean-up, seeks guidance, followsDemonstrates respect for diversity, culture, socioeconomic status, belies, and identity, 8. Time management skills: 1020304 Student is prompt, arrives on time, and completes assignments on time. a 3. Organization: 10 2030 40 Student is dependable, organized, and follows through with responsibilities. 10. Engagement in fieldwork experience: 10 2030 48 Demonstrates apparent level of interest, asks questions, actively participates while on site, and demonstrates interest in individuals and treatment outcomes. 11. Verbal communication and interpersonal skills with clients, staff, and caregivers: 10 2030 4 ‘Student interacts appropriately with individuals, such as eye contact, empathy, limit-setting, respectfulness, use of authority, and so forth; degree and quality of verbal interactions; use of body language and non-verbal communication. 12. Diversity 10 2030 4a facil step in and assist therapist as needed. She was able to revi plans. It was a pleasure having Danielle observe at our faci ies. ‘Comments: Danielle offered great communication and asked appropriate questions. She engaged in each of the 's she visited with patients and therapists to gain the most out of her level 1 experience, Danielle was willing to atient records and understand goals and treatment Total Points = _43_/ 48 Final Review: & Pass - The student meets standards (36 - 42 points) O Pass - The student has exceeded standards (43+ points) Oi Fail - The student has NOT meet standards (35 points or less) Supervisor Signature: \ 1 <, f) 10/3023, AUK OTR ‘Student Signature: v U Date: