Creighton University
Department of Occupational Therapy
School of Pharmacy & Health Professions
Fieldwork Experience
PERSONAL DATA SHEET
Date: __________________
Last Name
First Name
MI
Phone # (Include area code)
Local Address (Include Street, City, State, Zip)
Email Address
Emergency Contact Name
Phone # (Include area code)
Relationship to Student
Cell Phone #
Emergency Contact Address (Include Street, City, State, Zip)
Student Medical Insurance Carrier
Policy Number
Professional Liability Insurance Coverage Limits CU: Midwest Medical Insurance Company
$1,000,000 - Any one claim
$3,000,000 - Any one annual period of insurance
$1,000,000 - Any one occurrence
OTD Curriculum
FALL
Year 1
OTD 302 Occupations and Occupational Therapy (3)
OTD 306 Health Conditions (3)
OTD 314 Occupation and Health: Population
Perspectives (3)
OTD 316 Professional Practice and Ethical Formation
Seminar (LAB) (4)
OTD 341 Neuroanatomy (3)
Year 2
OTD 400 Research Project Implementation I (1.5)
OTD 403 Neuro-Occupation (2)
OTD 423 Occupational Therapy with Older Adults
(LAB) (3)
OTD 433 Upper Extremity Evaluation and
Intervention II (LAB) (3)
OTD 435 Occupational Therapy with Children and
Youth I (LAB) (3)
OTD 442 Critical Analysis of Occupational Therapy
Practice (3)
OTD 460 Clinical Education Seminar I (1.5)
OTD 490 Level IC Fieldwork: Pediatric or Selected
Practice Setting (1)
Year 3
OTD 564 Professional Identity and Ethical
Perspectives in the Ignatian Tradition
(first 3 weeks only; online format) (3)
OTD 574 Professional Competency (last 12 weeks
only; online format) (.5)
OTD 571 Level IIB Fieldwork (last 12 weeks only) (12)
Electives - Fall
SPRING
SUMMER
OTD 300 Research Proposal (3)
OTD 317 Occupational Therapy in Mental Health
(LAB)
(4)
OTD 318 Level IA Fieldwork: Mental Health (.5)
OTD 324 Applied Kinesiology (LAB) (3)
OTD 339 Clinical Anatomy (3)
OTD 340 Clinical Anatomy Lab (1.5)
OTD 355 Physical Rehabilitation I: Evaluation (LAB)
(3)
OTD 356 Physical
Rehabilitation II:
Neurorehabilitation (LAB)
(4)
OTD 333 Upper Extremity
Evaluation
and Intervention I (LAB) (3)
OTD 390 Level IB Fieldwork:
Physical
Rehabilitation (1.5)
OTD 401 Research Project Implementation II (1.5)
OTD 406 Management and Program Development
(3)
OTD 417 Disability and Healthcare Policy (3)
OTD 436 Occupational Therapy with Children and
Youth II (LAB) (4)
OTD 457 Physical Rehabilitation III: Interventions
and
Outcomes (LAB) (4)
OTD 461 Clinical Education Seminar II (1.5)
OTD 491 Level ID Fieldwork: Pediatric or Selected
Practice Setting (1)
OTD 481
Level IIA Fieldwork (12)
OTD 600 Professional Rotation (16)
OTD 601 Capstone (1)
Electives - Spring
Summary
Spanish for Health Professionals (2)
CHIP (1-3)
Spanish for Health Professionals (2)
Institute for Latin American Concern Program
(3)
Clarion Case Competition (1)
Spirituality in OT Practice
8 semesters
3 academic years
123 credits
36 classes
12 labs
43.5 weeks of clinical
experiences
Rotation
Personal Data Sheet, page 2
NAME:
•• Previous fieldwork experiences (experiences without dates will be completed in the future):
Fieldwork Site Name
Dates
Client diagnoses/ages
Level I A
Level I B
Level I C
Level I D
Level IIA
Level II B
• What do you feel are your strengths?
• What do you feel are your growth areas?
• Areas of interest, activities, hobbies, etc.:
• What do you expect to gain from your fieldwork experience:
• Do you have reliable transportation for your week of fieldwork? YES
NO
Students: Please attach your resumé to supplement this Personal Data Sheet.
STUDENT CLINICAL PARTICIPATION AND CONFIDENTIALITY AGREEMENT
SITE is committed to quality health care and confidentiality for its patients. As a student of another institution
assigned to a clinical experience at SITE, the undersigned is required to agree to the terms of this Agreement.
Please review and ask questions if you have any.
“Confidential Information” is any patient, physician, employee, and SITE business information obtained during
the course of work or association with SITE.
I agree to treat all Confidential Information as strictly confidential and will not reveal or discuss Confidential
Information with anyone who does not have a legitimate medical and/or business reason to know the
information. I understand that I am permitted to access Confidential Information only to the extent necessary for
patient care and to perform my duties while assigned to SITE. I will not disclose identifiable Confidential
Information (e.g., name, date of birth) if the identity of the individual can be removed. I understand that I am a
member of SITE’s workforce for purposes of complying with the Health Insurance Portability and
Accountability Act of 1996, and its applicable privacy and security regulations, and agree to follow SITE’s
policies regarding HIPAA while participating in this Clinical Program at SITE.
I will abide by all SITE policies and procedures regarding Confidential Information.
If I am given any access security codes or passwords, I agree to use them solely to perform my duties and will
not breach the security of the information systems or premises. I will not use or disclose or misuse security
codes or passwords. I will not misuse or attempt to alter SITE information systems in any way. I understand that
SITE reserves the right to audit, investigate, monitor, access, review and disclose information obtained through
the information systems at any time, with or without advance notice to me and with or without my knowledge.
I understand I will be held accountable for my work and any changes made under my password and security
codes. I understand that I am responsible for the accuracy of information submitted under my passwords and
security codes.
I am expected to be covered by my own health insurance at all times, including hospitalization insurance.
Should I seek routine or emergency medical care, I understand that I will be responsible for the cost of such
care.
I am not and will not be an employee of SITE by virtue of my participation in this Clinical Program at Site and
shall not be entitled to compensation or employee benefits of any kind, including but not limited to health
insurance, workers’ compensation insurance or unemployment benefits.
I understand that violations of SITE policy may subject me to immediate termination of my assignment at SITE,
as well as civil sanctions and/or criminal penalties.
My signature acknowledges that I have read and understand this Agreement.
_________________________
Student Name (print)
_________________________
Date
_________________________
Student Signature
_________________________
Name of Fieldwork Site
HEALTH STATUS/CLINICAL PROGRAM TRAINING
ATTESTATION FORM
1. I verify the following information for the required health screenings, immunizations or documented
health status and will provide documentation upon request.
a. Tuberculosis screening within the past 12 months (negative PPD skin test or a chest x-ray and health
care provider review if a previous positive PPD reaction) dated: ____________________
b. Measles, mumps, and rubella (MMR) immunity (positive antibody titers or 2 doses of MMR) dated:
__________ and ____________
c. Diphtheria, pertussis, and tetanus immunity (Tdap, Adacel, or Boostrix) dated: _________________
d. Polio immunity (3-dose series or positive antibody titer) dated: _____________________________
e. Varicella immunity (positive history of chickenpox and positive antibody titer or Varicella
immunization dated: ___________________________
f. Hepatitis B immunity (3-dose series and positive antibody titer) dated: _______________________
g. Seasonal flu vaccine dated: ________________
2. Creighton provides the following required program instruction to all students. I verify that I have
received instruction in all areas:
 CPR for Healthcare Providers date: ______________ Recommended Renewal: ___________
 Confidentiality (Patient Rights)
 Dress Code
 Universal Precautions, including needle safety date: __________________
 HIPAA training date: ___________________________
3.
I attest that a retrospective background check was completed upon my admission to the School of
Pharmacy and Health Professions. Unless SITE is notified in writing all background checks are
negative. The background check included the following reviews:
a. Society Security number verification
b. Criminal search (5 years)
c. Violent Sexual Offender and Predator registry
d. HHS/OIG/GSA
I agree to abide by all policies and procedures of the sites hosting my rotations/clinical experiences.
My signature acknowledges that the information I have provided is complete and accurate and that I authorize
the above information to be disclosed to preceptors/sites prior to rotations/clinical experiences.
_________________________________
Student Name (print)
_________________________________
Student Signature
_______________________
Date
This form will be sent to your fieldwork educator to assist in planning your clinical experience.