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COLL I: G E 1" H [ALT H Division of Occupational Therapy
FIELDWORK I OBSERVATION OF STUDENT PERFORMANCE
Student's Name: )(?/4!&~ 0M,~
( Fieldwork Facility: _IM___._.u..___ _ _ _ _ _ _ _ _ _ __
Supervisor's Name: v L:\ :0£1 ¥2tW½J'1Jl'v Dates of FW: ~1,0- ~t/122
Pl ease c heck the mos aooropnate ratinq:
Professional Behavior Needs Not
The student: Outstanding Adequate Improvement Observed
1. Conforms to institution's dress code.
2. Is responsible and dependable in attendance and promptness. 1/
3. Communicates effectively with other professionals/staff. Listens and speaks at
aoorooriate times. V
4. Contributes toward open communication with supervisor. Gives and receives feedback
aoorooriatelv.
5. Establishes and maintains therapeutic relationships with clients and their families.
6. Demonstrates professional values and ethics. v
7. Maintains the confidentiality of others.
8. Seeks information and asks relevant questions.
Uses resources and time effectivelv.
9. Follows through with suggestions made by supervisor.
10. Seeks challenges and demonstrates enthusiasm for fieldwork experiences.
11 . Demonstrates independence when appropriate.
12. Flexible: effectively adjusts to changes; adjusts priorities without difficulty.
Related to Educational Objectives Needs Not
Outstanding Adequate Improvement Observed
The student has:
13. Developed an increased comfort level interacting with persons who have disabilities,
emotional problems, or osvchiatric disorders. t/
14. Described the needs of clients served by the agency/facility.
15. Demonstrated respect for the values and diversity of persons with disabilities,
careoivers, staff and volunteers.
16. Demonstrated an attitude of inquiry to enhance creativity and problem solving skills.
v
1/
17. Observed staff interactions, assessments and/or treatment sessions with agency/facility
clients. v
18. Participated in group or individual treatment sessions as appropriate depending on the
skill level of the student and the severitv of the client's disability/illness. v
19. Observed OTR/COTA role delineation when Certified Occupational Therapy Assistants
are employed by the aqencv/facilitv.
i/
 Strengths of the student noted at this fieldwork:
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Areas the studenf coulaw6r~ toward improving during rema ining fieldwork experiences:

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Student Signature Supervisor Signature

Please give to the student to return, or mail to:

Jeanette Koski, OTR/L

Academic Fieldwork Coordinator
Division of Occupational Therapy
University of Utah
520 W akara Way
Salt Lake City, UT 84108- 1290