Ot Observation Form - School Of Health Professions

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Updated April 2017
FORM REQUIRED
DUPLICATE FORM AS NEEDED
University of Missouri ~ School of Health Professions
Department of Occupational Therapy
OCCUPATIONAL THERAPY OBSERVATIONS
Twenty (20) hours observation of Occupational Therapy by licensed Occupational Therapist
REVIEW Guidelines on page 2
To be filled out by applicant
Applicant’s Name ______________________________________________________________________________
Facility______________________________________________________________________________________
name
city
state
zip
TO BE FILLED OUT BY LICENSED OCCUPATIONAL THERAPIST
TYPE OF SETTING (PLEASE CHECK ONE)
In-patient
Out-patient
Home Health
School
Long Term Care
Other:_______________________
DATES for this experience ________________________________________ TOTAL # hours ______________
SUMMARY OF DIAGNOSIS AND TREATMENT OBSERVED_____________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
I certify that the above applicant has observed a licensed occupational therapist at this facility.
PRINTED Name of Licensed Occupational Therapist ______________________________________________
EMAIL _____________________________________________________________________________________
___________________________________________
_______________________
____________________
SIGNATURE of Licensed Occupational Therapist
State License #
DATE
or state certification #
May we contact you with questions about this applicant? (please circle)
YES
NO
This form is to be completed by OT/L, with OT/L signature
and returned to student for submission with application.

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