Fill - Free fillable Midterm Student Feedback Form Level 2 (Eastern Michigan University) PDF form

Level II Fieldwork Midterm Feedback Form

This form should be utilized as a companion document to the AOTA Fieldwork Performance Evaluation

(FWPE) for midterm review. The form is to be completed by the student and discussed with the

fieldwork educator after

the student’s FWPE midterm review. It is hoped that this document will assist

the student in identifying personal strengths, areas for growth, and further needs from the fieldwork

educator, as well as facilitate discussion between the fieldwork educator and student regarding the

student’s status at midterm. This form should be signed by both the student and the fieldwork

educator. It is the responsibility of the student to return this form to the Academic Fieldwork

Coordinator.

Student: ________________________________________________ Date: _____________________

Fieldwork Educator(s): __________________________________________________________________

Agency: ______________________________________________________________________________

Midterm Score on FWPE: __________

ORIENTATION:

1. Did you receive an adequate orientation to the facility/documentation forms/expectations/

safety and precaution procedures? Do you feel the need for further or additional orientation?

______________________________________________________________________________

2. Have you been made to feel welcome at this agency?

______________________________________________________________________________

3. Were expectations clearly defined during the orientation period?

______________________________________________________________________________

ASSIGNMENTS/CLIENT CASELOAD:

1. Do you have a clear understanding of all assignments and what is expected as well as rationale

behind assignments? Elaborate please.

______________________________________________________________________________

2. Are you completing required documentation and assignments as required and in a timely

manner? What are the time requirements for documentation? Elaborate please.

______________________________________________________________________________

3. What is your current caseload like (number of clients, types of diagnoses, etc.)? Do you feel that

you are maintaining a client caseload that is appropriate for your skill level at this time?

Elaborate please.

______________________________________________________________________________

SUPERVISION:

1. Identify ways and areas in which supervision from your fieldwork educator has been helpful.

______________________________________________________________________________

2. Identify ways and areas in which you would like further supervision.

______________________________________________________________________________

3. Are you receiving feedback in a timely manner? Has the feedback been constructive? Elaborate

please.

______________________________________________________________________________

COMMUNICATION:

1. Has communication with your fieldwork educator been open and constructive?

______________________________________________________________________________

2. What are some ways you could improve communication with your fieldwork educator? With

your clients? Elaborate please.

______________________________________________________________________________

3. Do you feel comfortable seeking assistance from professional staff and personnel from other

disciplines? Elaborate please.

______________________________________________________________________________

4. Have you had the opportunity to supervise OTAs or OT aides? Do you feel ready for this

responsibility? What guidance do you feel you need to be successful with this responsibility?

Elaborate please.

______________________________________________________________________________

5. Are you comfortable with oral reports with instructor/during staff or department meetings/

family/client conferences? What ideas do you have for improvements? Elaborate please.

______________________________________________________________________________

6. Are you comfortable with written reports with daily documentation/ interdisciplinary reports?

What ideas do you have for improvements? Elaborate please.

______________________________________________________________________________

PROFESSIONALISM/ PERSONAL DEVELOPMENT:

1. Have you encountered a situation in which you felt that you were truly “an OT” and felt

confident in your skills? Please describe the situation and your actions.

______________________________________________________________________________

2. Have you encountered a situation in which you felt that you were not prepared to deal with? If

so, please describe the situation, how/why you did not feel prepared, and the actions you took.

Describe in what ways you feel that the situation should have been handled.

______________________________________________________________________________

3. Identify your strengths.

______________________________________________________________________________

4. Identify skills and areas for future development that are important to you.

______________________________________________________________________________

MIDTERM OBJECTIVES:

Based on what you thought about when filling out this form and the feedback that you received on your

midterm Fieldwork Performance Evaluation (FWPE), develop at least 3

site-specific objectives for the

remainder of your placement that will facilitate your achievement of entry-level competence at this

agency. These objectives should be developed in collaboration with your fieldwork educator.

1. ______________________________________________________________________________

______________________________________________________________________________

2. ______________________________________________________________________________

______________________________________________________________________________

3. ______________________________________________________________________________

______________________________________________________________________________

4. ______________________________________________________________________________

______________________________________________________________________________

5. ______________________________________________________________________________

______________________________________________________________________________

6. ______________________________________________________________________________

______________________________________________________________________________

Student Signature: ________________________________________ Date: ____________________

Fieldwork Educator Signature: _______________________________ Date: ____________________

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