SUPERVISOR EVALUATION OF STUDENT

Listening Skills

Professional Dress

LATI OTA Program

Level I Fieldwork

Supervisor Evaluation of Level I Student

Supervisor Name: _______________________________________Student Name: _________________________________

Facility Name ___________________________________________________________________Date: ________________

**To the Supervisor: Please rate the student’s skills as you observed from 1.0-4.0 using the scale below. Please circle your response for each category. If more space is needed for comments, the back of this page can be utilized. A student’s overall grade will be determined by averaging the scores. A total of 32 are required to pass.

Listening Skills
1.0 No listening skill present	1.5		2.0	2.5	3.0	3.5	4.0 Excellent listening skills
Verbalization Skills
1.0 Limited verbal skills	1.5		2.0	2.5	3.0	3.5	4.0 Excellent verbal skills
Initiative
1.0 No initiative	1.5		2.0	2.5	3.0	3.5	4.0 Excellent initiative
Behavior
1.0 Immature Behavior	1.5		2.0	2.5	3.0	3.5	4.0 Professional Behavior
Dependability
1.0 Unreliable	1.5		2.0	2.5	3.0	3.5	4.0 Excellent dependability
Professional Dress
1.0 Inappropriate dress	1.5		2.0	2.5	3.0	3.5	4.0 Appropriate dress
Time Management
1.0 Limited time management skills	1.5		2.0	2.5	3.0	3.5	4.0 Utilized time effectively
Assignments/Learning Experiences
1.0 Didn’t participate	1.5		2.0	2.5	3.0	3.5	4.0
Supervisory relations
1.0 Limited ability to interact with supervisor		1.5	2.0	2.5	3.0	3.5	4.0 Excellent Supervisory skills
Professional awareness
1.0 No professional awareness		1.5	2.0	2.5	3.0	3.5	4.0 Excellent professional awareness

Supervisor Comments

Signatures indicate that both parties have read and discussed the information contained in the supervisor evaluation of student form

Clinical Supervisor Signature: ____________________________________ Date__________________

LATI OTA Student Signature: ______________________________________ Date________________