This form is to be completed by a licensed Occupational Therapist, or Occupational Therapy Assistant. Forms completed by anyone other than an OT or OTA will not be accepted. Volunteer experiences cannot be evaluated by a relative or personal friend. Please present this form to your supervising therapist with a stamped envelope addressed to the OTA Program. The total number of required hours is 40, divided between 2 different sites, 20 hours each. Please complete the next section completely.
A. Applicantâ€™s Name
B. Facility Name & Address
C. Facility Phone Number
D. Number of Hours Completed
E. Please sign the following waiver prior to giving this form to the supervising therapist.
I waive the right to view this completed form in order to afford an unbiased evaluation by the supervising therapist.
II. OCCUPATIONAL THERAPY PRACTITIONER:
Please rate the applicant on the following behavioral characteristics:
|Characteristics||Above Average||Average||Below Average|
|a. Professional behaviors (dress, punctuality, etc.)|
|b. Communication & interaction skills|
|c. Ask relevant questions|
|d. Ability to relate to clients|
|e. Organization & preparation for observation (scheduling, understanding facility population)|
_______ Highly recommended
_______ Recommend with reservation
_______ Not recommended
Printed Name of Evaluator: ____________________________________________________________________
Signature ____________________________________________________ State & License No. ________________
PLEASE NOTE: VOLUNTEER HOURS WILL NOT BE ACCEPTED IF MORE THAN TWO YEARS OLD.
PLEASE MAIL TO:
Harriett S. Bynum, MS, OTR/L
Occupational Therapy Assistant Program
Kent State University
East Liverpool Campus
400 East Fourth St.
East Liverpool, OH 43920