Occupational Therapy Assistant Program Clinical Observation Rating Form
Bossier Parish Community College
6220 East Texas Street
Bossier City, Louisiana 71111
Kelly Brandon, Program Director
Phone: 318-678-6471
Fax: 318-678-6199
The Clinical Observation Rating Form is utilized by the Bossier Parish Community College OTA Program in the clinical
selection process. Indicate the rating that BEST describes the named applicant in each of the categories. Consider the
listed criteria as a reference when making your selection.
Instructions for the Applicant.
Print this form. Provide printed form to the OT or OTA you
observed along with a STAMPED envelope ADDRESSED
Bossier Parish Community College
Attn: OTA Program Selection Committee
6220 East Texas Street
Bossier City, LA 71111
Instructions for the Clinician
Place the completed form in the addressed/stamped envelope provided to you by the observer. Seal the envelope and place
your signature across the seal before mailing.
Completed forms may also be emailed. Please contact Kelly Brandon at kbrandon@bpcc.edu or Michele Allison at
mallison@bpcc.edu for further assistance.
Applicant Information
Applicant: _________________________________________________________________________________
Evaluator Information
Date of Form Completion: _________________________Name of OT/OTA:_____________________________________
Dates of Observation: _____________________________ ______________
Total Number
Hours Applicant Observed:
Phone Number: __________________________________ OT/OTA email: _____________________________________
Facility in Which Observation Was Performed:
Demographic Information
In what capacity have you known the applicant (mark all that apply)?
Unknown prior to Observation Friend or friend of family Patient
Other, please elaborate: _________________________________________________________________
How long have you known the applicant? ____________________________________
1=Poor or
2= Below
3= Average
4=Good or
Above Average
5=Excellent or
Category Criteria on which to rate applicant Rating
-Dresses like a professional
-Abides by dress code
-Neat with good personal hygiene
1 2 3 4 5 not applicable
Enthusiasm and
Interest in the
Clinical Setting
-Sincerely and appropriately enthusiastic
-Asks appropriate questions 1 2 3 4 5 not applicable
Time Management
Skills and
-Punctual & uses observation time
-Is considerate of therapist & patient needs
with regard to time
-Seeks unique observation activities
1 2 3 4 5 not applicable
Oral Communication -Uses appropriate grammar
-Expresses ideas clearly
-Uses terminology appropriately to subject
matter and audience
1 2 3 4 5 not applicable
-Appropriate eye contact
-Listens Attentively
-Body Language
1 2 3 4 5 not applicable
People skills -Displays evidence of being a “people
-Makes an effort to get along with others
-Has a likeable personality
-Is friendly and warm with patients
1 2 3 4 5 not applicable
Role Acceptance -Relates well to authority
-Accepts constructive criticism
-Makes suggested changes in performance
1 2 3 4 5 not applicable
Attitude -Keeps a positive attitude
-Displays optimism
1 2 3 4 5 not applicable
Maturity in the
Clinical Setting
-Demonstrates mature behavior relative to
patient care situations
-Exercises discretion with both words and
-Is appropriate and concerned with patient
modesty, if applicable
1 2 3 4 5 not applicable
What is your impression of this student’s overall ability to succeed with the clinical interaction requirements of the Allied Health
Program for which this student is an applicant?
1. = I do not believe this student has the interpersonal readiness to succeed with demanding curriculum
2. = I have reservations relative to this student’s interpersonal ability and/or motivation
3. = Interpersonal ability to succeed in clinicals, but may need to work on improving these skills
4. = Above average interpersonal ability to succeed in clinicals
5. = Outstanding interpersonal ability to succeed in clinicals
Based on your interactions with this applicant please offer a recommendation to the program selection committee
1. =I DO NOT recommend this applicant
2. =I give this student an average recommendation with some hesitation based on reasons I have indicated
3. =I give this student an average recommendation
4. =I give this applicant a good recommendation
5. =I reserve my highest recommendation for this applicant