AOTA FIELDWORK DATA FORM Date: Name of Facility: Address: City: State: Zip Code: FW Level II FW Level I (if different) Contact Person: Credentials: Contact Person: Credentials: Phone: E-mail: Phone: E-mail: Director: Corporate Preferred Sequence of FW: Phone: Status: Standards B.10.6 Any Fax: For Profit Second/Third only; 1st must be Web site address: Non-Profit in: State Gov’t Full-time only Part-time Federal Gov’t option Prefer Full-time OT Fieldwork Practice Settings (ACOTE Form A #s noted): (Click on boxes to check) Community-based settings School-based Age Number of settings settings Groups: In-Patient Peds Community 2.1 Early 0-5 OTRs: Acute 1.1 Behavioral Health Intervention 3.1 6-12 In-Patient Rehab 1.2 Community 2.2 School 3.2 13-21 Aides: SNF/ Sub-Acute/ Older Adult Community 22-64 PT: Acute Long-Term Care Living 2.3 65+ Speech: area(s) 1.3 Older Adult Day Program Resource please specify: General Rehab 2.4 Teacher: Outpatient 1.4 Outpatient/hand private Outpatient Hands 1.5 practice 2.5 Pediatric Adult Day Program for DD Other: Hospital/Unit 1.6 2.6 Peds Hospital Home Health 2.7 Outpatient 1.7 Peds Outpatient Clinic In-Patient Psych 1.8 2.8 Student Requirements/Prerequisites (Check Health requirements: all that apply): (Click on boxes to check) ACOTE C.1.2 CPR First Aid HepB Physical Check up type required: Infection MMR Varicella Medicare / Medicaid Fraud Control training Tetanus Influenza Check HIPAA Training Chest x-ray Criminal Background Check Prof. Liability Drug screening Please list any Protection/abuse Ins. # 10 Panel requirements: check Own TB/Mantoux Adult abuse check transportation Fingerprinting Interview
AOTA FIELDWORK DATA FORM Date: Name of Facility: Address: City: State: Zip Code: FW Level II FW Level I (if different) Contact Person: Credentials: Contact Person: Credentials: Phone: E-mail: Phone: E-mail: Director: Corporate Status: For Profit Non-Profit State Gov’t Federal Gov’t Preferred Sequence of FW: Standards B.10.6 Any Second/Third only; 1st must be in: Full-time only Part-time option Prefer Full-time Phone: Fax: Web site address: OT Fieldwork Practice Settings (ACOTE Form A #s noted): (Click on boxes to check) settings Community-based settings School-based settings Age Groups: Number of In-Patient Acute 1.1 In-Patient Rehab 1.2 SNF/ Sub-Acute/ Acute Long-Term Care 1.3 General Rehab Outpatient 1.4 Outpatient Hands 1.5 Pediatric Hospital/Unit 1.6 Peds Hospital Outpatient 1.7 In-Patient Psych 1.8 Peds Community 2.1 Behavioral Health Community 2.2 Older Adult Community Living 2.3 Older Adult Day Program 2.4 Outpatient/hand private practice 2.5 Adult Day Program for DD 2.6 Home Health 2.7 Peds Outpatient Clinic 2.8 Early Intervention 3.1 School 3.2 area(s) please specify: 0-5 6-12 13-21 22-64 65+ OTRs: Aides: PT: Speech: Resource Teacher: Other: Student Requirements/Prerequisites (Check all that apply): (Click on boxes to check) ACOTE C.1.2 Health requirements: CPR type required: Medicare / Medicaid Fraud Check Criminal Background Check Protection/abuse check Adult abuse check Fingerprinting First Aid Infection Control training HIPAA Training Prof. Liability Ins. Own transportation Interview HepB MMR Tetanus Chest x-ray Drug screening # 10 Panel TB/Mantoux Physical Check up Varicella Influenza Please list any requirements:
AOTA%20FIELDWORK%20DATA%20FORM_LSU.docx