Fieldwork Data Form - University Of Southern Maine Page 3
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4Student Information
____ Room provided:
Meals:
____ on grounds
____ Breakfast ____ Lunch ____ Dinner
____ off grounds
____ Free ____ At cost ____ Purchase
____ Housing available:
Hours:
Student pays $_____/mo.
_______________ Weekdays
_______________ Evenings
____ Stipend:
_______________ Weekends
Hr. $____ Mo. $____ Session $____
_______________ Variable
____ Access to Public Transportation
Other _______________________________
Dates: Use AOTA suggested dates _________
Use own dates _________
Student Supervision
Check all that apply:
_____ 1:1 Model
_____ Multiple students : one supervisor
_____ Multiple supervisors : one student
Low
High
Structure provided to students
1
2
3
4
5
(objectives, week-to-week guidelines)
Low
High
Nature of Supervision
1
2
3
4
5
Ending Student Expectation/Productivity
# of clients per week
% productivity expectation
OCCUPATIONAL THERAPY STAFF PROFILE
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Parent category: Business