AOTA FIELDWORK DATA FORM

Date:

Name of Facility:

Address: Street: City: State: Zip:

FWII
Contact Person: Credentials:
Phone:Fax:
Email:Website: / FWI
Contact Person:Credentials:
Phone:Fax:
Email:Website:
OT Fieldwork Practice Settings(check all that apply):
Hospital-based settings
In-Patient Acute 1.1
In-Patient Rehab 1.2
SNF/Sub-Acute 1.3
General Rehab Outpatient 1.4
Outpatient Hands 1.5
Pediatric Hospital In-Patient 1.6
Pediatric Hospital Outpatient 1.7
In-Patient Mental Health 1.8
Nursing Home/LTC 1.9 / Community-based settings
Pediatric Community 2.1
Mental Health Community 2.2
Older Adult Community Living 2.3
Older Adult Day Program 2.4
Outpatient General Private Practice 2.5
Outpatient Hand Private Practice 2.5.1
Adult Day Program for DD 2.6
Home Health 2.7
Pediatric Outpatient Clinic 2.8
Work Program/Hardening 2.9
Assistive Technology 2.10 / School-based settings
Early Intervention 3.1
School 3.2
Other Area(s):
Please specify: / Age Groups
0-3 yrs
3-5 yrs
6-12 yrs
13-21 yrs
Adult
Older Adult
Primary Conditions for which Occupational Therapy is administered(check all that apply):
Adjustment Disorder
Affective Disorder
Alzheimer’s Disease
Amputation
Anxiety Disorder
Arthritis
Autism/PDD
Back Injury
Burns
Cardiac Dysfunction
Cerebral Palsy
Chronic Pain
Congenital Anomalies / CVA/Hemiplegia
Degenerative Neuro Disorder
Developmental Disability
Dementia
Diabetes
Dysphagia/Feeding Disorder
Eating Disorder
Eating/Feeding Problems
Fractures & Gen Orthopedics
Hand/Wrist Disorder
Hearing Impairment
HIV/AIDS
Learning Disorder / Mental Retardation
Neuromuscular Disorder
Neonatology (NICU)
Oncology
Personality Disorder
Respiratory Disease
Schizophrenic Disorder
Spinal Cord Injury
Substance Abuse
Traumatic Brain Injury
Visual Impairment
Well Population
Other Conditions:
Please list the five (5) most common screenings and evaluations used in your setting:
1)
2)
3)
4)
5)
Types of OT Interventions/Models of Practice addressed in your setting (check all that apply):
Interventions:
A) Performance Areas
Activities of Daily Living (ADL)
Instrumental Activities of Daily Living (IADL)
Education
Work
Play
Leisure
Social Participation / B) Performance Skills
Motor
Praxis
Sensory
Perceptual
Emotional Regulation
Cognition
Communication
Social Skills / C) Special Interventions
Sensory Integration
Low-Vision Training
Assistive Technology
Driving Evaluation/Training
Animal Assisted Therapy
Aquatic Therapy
Other:
Theory/Frames of Reference/Models of Practice:
Acquisitional
Biomechanical
Cognitive-Behavioral
Coping
Developmental / Ecology of Human Performance
Model of Human Occupation (MOHO)
Occupational Adaptation
Occupational Performance Model
Person-Environment-Occupation (P-E-O) / Person-Environment-Occupational Performance
Psychosocial
Rehabilitation Frames of Reference
Sensory Integration
Other:
Information for Students:
Housing Available, cost:
Stipend:
Meals: Free Purchase
Access to Public Transportation, please specify:
Student Work Schedule:
Typical schedule:
Do students work weekends? Yes No
Do students work evenings? Yes No
Level of structure: High Moderate Low
Level of supervisory support: High Moderate Low
Please list how students should prepare for a FW II placement such as doing readings, learn specific evaluations and interventions used in your setting:
Student Prerequisites (check all that apply):
Interview
CPR
First Aid
Criminal Background Check
Child Protection/Abuse Check
Adult Abuse Check
Fingerprinting
Infection Control Training
HIPPA Training
Professional Liability Insurance
Own Transportation / Health Requirements:
HepB
MMR
Tetanus
Drug Screening
TB/Mantoux: 1-step 2-step
Physical Check-up
Varicella
Influenza
Other:
Target Caseload/Productivity:
Productivity % per 40 hour work week:
Caseload expectation at end of FW:
Productivity % per 8 hour day:
# groups per day expectation at end of FW:
Documentation:
Hand-written Documentation: Daily Weekly Monthly Annually
Computerized Medical Records: Daily Weekly Monthly Annually
Administrative/Management Duties (check all that apply, and please specify details):
Schedule own clients:
Supervision of others (level I students, aides, OTA, volunteers):
Budgeting:
Procuring supplies (shopping for cooking groups, client/intervention related items):
Participating in supply or environmental maintenance:
Other:
Student Assignments(check all that apply, and please specify details):
Research/EBP/Literature Review:
In-service:
Case study:
Participate in in-services/grand rounds:
Fieldwork project, please specify:
Field visits/rotations to other areas of service:
Observation of other units/disciplines:
Other assignments:
Supervision (check all that apply):
1:1 Supervision Model
Multiple students supervised by one supervisor
Multiple supervisors share supervision of one student; # supervisors per student:
Non-OT supervisor