Fieldwork Data Form - University Of Southern Maine
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4Fieldwork Data Form
DATE: Month __________ Year ______
This form refers to ___________________________________________________ fieldwork experience.
Length of fieldwork: ____________________ OT
____________________ OTA
Will Accept: ___ Full-time Student ___ Part-time Student ___ 1st Placement ___ 2nd Placement ___ 3rd Placement
Name of Center
Address/City/State/Zip
Center Phone: (
)
E-Mail Address:
Fax Number: (_______)__________________________ Director: ______
Person Responsible for Fieldwork Program
Name: _______________________________ Credentials: ________________ Phone: (
)
E-mail: ______________________
# of Staff: _____ OT (s) _____ OTA(s) _____ Support Staff
Approximate # of agreements with schools ________
Accreditation by: __________________________________________________________ Date ___________________
General Information
Setting
Description of Specialty
____ Hospital
(e.g. Acute Inpt, Outpt, Rehab Unit)
____ School
(e.g. Public School System)
____ Community Agency
(e.g. Psycho-Social Program, Homeless Shelter)
____ Private Practice (e.g. Pediatrics, Psych, Home Health)
____ Residential Program
(e.g. Developmental Delay, Mental Retardation)
____ Nursing Home
(e.g. Rehab Unit, Long Term Care)
____ Other
Ages served: ____ 0-3 yrs ____ 3-5 yrs
____ 6-12 yrs ____ 13-21 yrs ____ Adult ____ Older Adult
Primary Conditions for Which Occupational Therapy is Administered
____ Adjustment Disorder
____ Dementia
____ Mental Retardation
____ Affective Disorder
____ Diabetes
____ Neuromuscular Disorders
____ Alzheimer’s Disease
____ Dysphagia/Feeding Disorders
____ Neonatology (NICU)
____ Amputation
____ Eating Disorders
____ Oncology
____ Anxiety Disorder
____ Eating/Feeding Problems
____ Personality Disorder
____ Arthritis
____ Respiratory Disease
____ Fractures & Gen Orthopedics
____ Autism/PDD
____ Schizophrenic Disorder
____ Hand/Wrist Disorders
____ Back Injury
____ Spinal Cord Injury
____ Hearing Impairment
____ Burns
____ Substance Abuse
____ HIV/AIDS
____ Cardiac Dysfunction
____ Traumatic Brain Injury
____ Learning Disorder
____ Cerebral Palsy
____ Visual Impairment
____ Chronic Pain
____ Well Population
____ Congenital Anomalies
____ Other_______________________
____ CVA/Hemiplegia
____ Degenerative Neuro
Disorder
____ Developmental
Disability
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