FIELDWORK DATA FORM

This form refers to: Occupational Therapists and COTA’s fieldwork experience.

Length of Fieldwork: OT: Varies according to level and student needs COTA: Varies

Will Accept: X Full-Time Student(s) 0 Part-Time Student(s)

X 1st Placement X 2nd Placement X 3rd Placement

Name of Center: Vanderbilt Bill Wilkerson Center – Pediatric OT

Address/City/State/Zip: 1215 21st Ave. South, Suite 6209 Medical Center East- South Tower

Nashville, Tennessee 37232-8590 .

Center Phone: (615-322-2475) E-Mail Address:

Person Responsible for Fieldwork Program:

Name: Elizabeth Murillo Credentials: OTR/L Phone: (615)322-2475

Staff: 4 OTR(s) 0 COTA(s) 0 Support Staff Approximate # of Contracts with Schools: 5

Accreditation By: JCAHO Date: June, 2006

GENERAL INFORMATION

Setting

X__ Hospital
____School
____Community Agency
____Private Practice
____Residential Program
____Nursing Home
___OTHER /

Description of Specialty

(e.g. Acute inpt, Outpt, Rehab Unit)___Pediatric Outpatient
(e.g. Public School System)______
(e.g. Psycho-Social Program, Homeless Shelter)______
(e.g. Pediatric, Psych, Home Health)______
(e.g. Developmental Delay, Mental Retardation)______
(e.g. Rehab Unit, Long Term Care)______

Ages Served: X 0-5 Years X 6-12 Years 13-21 Years Adult Older Adult

Primary Conditions for Which Occupational Therapy is Administered

___Adjustment Disorder
Affective Disorder
__ Alzheimer’s Disease
__ Amputee
__ Anxiety Disorder
__Arthritis
X Autism/PDD
__ Back Injury
__ Burns
__Cardiac Dysfunction
X Cerebral Palsy
Chronic Pain
X Congenital Anomalies / __CVA/Hemiplegia
_X_Degenerative Neuro Disorder
X Developmental Disorder
_ Dementia
__ Diabetes
X Dysphagia/Feeding Disorders
Eating Disorders
_X_ Eating/Feeding Problems
__ Fractures & Gen. Orthopedics
__ Hand/Wrist Disorders
X Hearing Disability
__ HIV/Aids
X Learning Disorder
X Mental Retardation / X Neuromuscular Disorders
Neonatology
Oncology
Personality Disorder
X Pervasive Developmental Disorder

__ Respiratory Disease

Schizophrenic Disorder
__Spinal Cord Injury
Substance Abuse
__ Traumatic Brain Injury
__Visual Disability
Well Population
Ergonomics

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Fieldwork Data Form
ASSESSMENTS AND INTERVENTIONS

1.  Assessments:

BOT-2, VMI, DTVP, PDMS-2, Sensory Profile (infant/toddler, sensory profile and school sensory profile), ETCH, Print Tool, Minnesota Handwriting Assessment .

2.  Intervention:

Role of OT in Fieldwork setting: X Direct X In-Direct

Describe Intervention: ADL’s – Feeding for sensory-based deficits, developmental teaching.

Neuromusculosketetal – Strengthening, range of motion, postural control and muscle tone. .

Motor – Bilateral integration, praxis. Gross and fine motor coordination, visual motor control .

Sensory - Sensory awareness and processing ; perceptual processing, SOS feeding program. Discharge Planning – With family to address on-going therapy, home programs and/or community-based service options

Theoretical Model(s) Guiding Practice:

NDT, Sensory Integration/Sensory Processing Theory, Occupational Performance Model + Motor Learning\

PRE-REQUISITES

X CPR Physical Exam

X Pediatric CPR (if affiliation in Peds) X Criminal Background Check

X Universal Precautions (OSHA) Fingerprinting

__ Interview X Malpractice Inusrance

_ Car Required X Health Insurance

X Immunizations/Tests - Specify Type: X Other

See Vanderbilt University Medical Center The Academic Fieldwork Coordinator

Student/Instructor Health Screening and must communicate via writing or

Pre-requisite Checklist. Verbally with Elizabeth Murillo, MS, OTR/L,

Fieldwork Experience - Indicate Type: Clinical Coordinator, to assign students.

STUDENT INFORMATION

NO Room Provided Meals: N/A

_____on grounds ____Breakfast _____Lunch _____Dinner

YES Will assist student to find housing off campus with prices ranging from $300-$700/month.

Therapists are off major holidays.. No weekends. Students are expected to work the same schedules as his/her clinical instructor.

Dates: Use AOTA Suggested Dates: X Use Own Dates: X .

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Fieldwork Data Form

STUDENT SUPERVISION

Check all that apply: X 1:1 Model

Multiple Students: One Supervisor

X Multiple Supervisors: One Student (no more than 3 supervisors)

Students are given the opportunity to spend days with therapists in other

areas/facilities (ex: Vanderbilt Children’s Hospital, Susan Gray School for Children, etc. Students have the opportunity to attend rounds and other medical center-based continuing education.

Structure Provided to Students: Low High

1 2 3 (4) 5

Students are provided with week-to-week guidelines and objectives.

Nature of Supervision

Specific to different CI’s : Low High

1 2 3 (4) 5

Ending Student Expectation/Productivity: Varies Number of Clients per Week

__62% Productivity Expected (OT’s)

__Productivity Expected (COTA’s)

By the end of week 9 students are expected to be functioning as entry-level therapists/

Function as an entry-level therapist: OT’s = 5 hours of productivity/day – approximately 24 RVU’s/week

R.V.U.’s Relative Value Units (60 minutes of time)

NAME / TITLE / DEGREE AND
COLLEGE/UNIVERSITY / YEARS
IN OT / OT
SPECIALTY
Elizabeth Murillo / OTR / MS, Chatham University / 10 / Pediatrics, School system, early childhood
Hayley Hinds / OTR / OTD, Belmont Universiy / 1 / Pediatrics
Katy Dieckhaus / OTR / MS, Washington University / 5 / Pediatrics, Feeding
Erin / OTR / OTD, Belmont University / 1 / Pediatrics

Vanderbilt University Medical Center is a comprehensive health care facility dedicated to patient care, research and education. It’s reputation for excellence in each of the areas has made Vanderbilt a major patient referral center for the Mid-South. Each year over 300,000 people choose Vanderbilt University Medical Center for their health care needs. Vanderbilt University Medical Center is a twin towered, 658-bed structure with the most up-to-date systems and technology. The hospital is also home to the region’s only Level I Trauma Center, Burn Unit and the most comprehensive Neonatal Intensive Care Unit.

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Fieldwork Data Form

VANDERBILT UNIVERSITY MEDICAL CENTER

REHABILITATION SERVICES MISSION STATEMENT

v  To maximize functional independence by providing up-to-date, customer focused and cost effective treatment to our patients.

v  To encourage and emphasize each patient’s role as an active participant in their own care and rehabilitation.

v  To keep our referral sources informed on patient’s progress by concise, accurate and timely evaluations and progress reports.

v  To provide out patients and communities with preventative education and safe methods to perform daily activities.

v  To provide well-organized clinical education experiences for rehabilitation professionals and students.

v  To be active consumers of, and participants in rehabilitation research.

AOTA Commission on Education (ICOE and Fieldwork Issues Committee (FWIC)

Amended and Approved by FWIC 11/99 and COE 12/99.

July 2007/vs