Department of Occupational Therapy

advertisement
CREIGHTON UNIVERSITY
DEPARTMENT OF
OCCUPATIONAL THERAPY
FIELDWORK STUDENT MANUAL
INTRODUCTION
This manual has been prepared to help you understand the policies and procedures of
clinical education. The Academic Clinical Education Coordinators and the Assistant
Clinical Education Coordinator will be available to clarify any information. Communication
is essential for a successful collaborative effort in placing students in fieldwork
experiences. Your questions are always welcomed.
The University reserves the right to change and to make exceptions to the provisions
of this manual at any time and to apply any change or to make an exception
applicable to any student without regard to date of admission application or date of
enrollment. This manual is neither a contract nor an offer to enter into a contract. A
current version of this manual is posted on the Creighton University Department of
Occupational
Therapy
Clinical
Education
website:
http://spahp2.creighton.edu/offices/occupationaltherapy/fieldwork/Home.aspx
Anna Domina, OTD, OTR/L
Academic Clinical Education Coordinator
(402) 280-3407
[email protected]
Angela Patterson, OTR/L
Occupational Therapy Adjunct Faculty
(402) 280-5980
[email protected]
Andrea Thinnes, OTD, OTR/L
Director, Clinical Education Office
Academic Clinical Education Coordinator
(402) 280-5929
[email protected]
Mary Pat Wearne
Assistant Clinical Education Coordinator
(402) 280-5631
[email protected]
Clinical Education Website
http://spahp.creighton.edu/departments-offices/occupational-therapy/clinical-education-department
AOTA Fieldwork Website
http://www.aota.org/Students/Current/Fieldwork.aspx
Clinical Education SharePoint Website
http://otclined.creighton.edu
Fieldwork Student Manual
updated 1/2014
2
TABLE OF CONTENTS
Introduction ............................................................................................................... 2
Preparation for All Fieldwork .............................................................................. ……4
Level I Fieldwork ..................................................................................................... 11
Level II Fieldwork .................................................................................................... 14
Site Development ................................................................................................... 19
Level II Fieldwork Evaluation Process…………………………………………………..21
What to Expect During Fieldwork ........................................................................... 26
Universal Precautions ............................................................................................ 27
HIPAA Regulations ................................................................................................. 29
Entry-Level Professional Rotation ........................................................................... 31
NBCOT and Temporary Licensure .......................................................................... 32
Appendices
Appendix A:
Appendix B:
Appendix C:
Appendix D:
Appendix E:
Appendix F:
Appendix G:
Appendix H:
Appendix I:
Appendix J:
Appendix K:
Appendix L:
Appendix M:
Appendix N:
Appendix O:
Appendix P:
Appendix Q:
Appendix R:
Clinical Plan of Study ........................................................................ 33
Personal Data Sheet ......................................................................... 40
Sample Level I Site Preference Sheet .............................................. 45
Level IB-ID Fieldwork Evaluation ...................................................... 47
Level IB-ID Student Evaluation of Site ............................................... 50
Level II Fieldwork Preference Form .................................................. 54
Level II Assignment Agreement ........................................................ 56
Level II Fieldwork Confirmation ......................................................... 58
Level II Student Evaluation of Site (SEFWE) .................................... 60
Level II Fieldwork Evaluation (FWPE) ............................................... 70
FEAT ................................................................................................ 79
Fieldwork Checklist ........................................................................... 85
Writing to a Fieldwork Site ................................................................ 87
Sample Thank You Letter ................................................................. 89
Site Recommendation Form ............................................................. 90
Student Liability Coverage ................................................................ 93
Incident Report Form ......................................................................... 95
Verification of Receiving/Reviewing Fieldwork Student Manual ......... 98
Fieldwork Student Manual
updated 1/2014
3
PREPARATION FOR ALL FIELDWORK

Experiential Education Participation Policy:
To protect the health of Creighton University School of Pharmacy and Health
Professions (SPAHP) students and the patients they serve, and in accordance with
contractual arrangements with varied health-related institutions, students in programs
which have an experiential education component must meet specified requirements
including immunizations, health insurance coverage, and acceptable criminal
background checks before being enrolled in any of the School’s practice-based
academic programs.
Students in programs which have an experiential education component must remain
compliant with the immunization, health insurance coverage, and acceptable criminal
background check requirements, as well as achieving and maintaining cardiopulmonary
resuscitation (CPR) certification, and completing training in universal precautions and
HIPAA requirements before they can participate in experiential education activities.
Proof of compliance with all of the items listed above will be required by Experiential
Education Directors, and may be required by fieldwork educators/fieldwork educators,
before students can be placed or accepted at educational practice sites. Students who
have failed to remain compliant with these requirements will not be allowed to
participate in experiential education activities and may be subject to dismissal from the
School. At a minimum, non-compliance with this policy may impact or delay the
student’s date of graduation.
Any specific health requirements, drug testing or criminal background checks
required by a site will need to be completed prior to participation in any/all fieldwork.
These requirements are the responsibility of the student.
Students requiring a background check may use CERTIPHI. Creighton University has
asked that you use the Application Station - Student Edition to complete necessary
screening services.
To do so, please follow the instructions below:
1. Click the link or paste it into your browser: http://www.applicationstation.com
2. Enter the Code: CREIGHTON-RECHECK in the Application Station Code field.
3. Click the "SIGN UP NOW" button to create an account.
4. Follow the instructions on the Application Station web site.
If you have questions regarding this request, please contact Mary Pat Wearne 402-2805631.
If you have technical issues visiting the Application Station site, please contact
Application Station Support at: 888-291-1369 x2006.
Also let Mary Pat know whether your site needs a copy of the report or just a letter
verifying the results of the background check (most sites do not want to see the
background check, they only want to know that it has been done and confirmation that
the results are clear --- check with your FWEd to find out exactly what they need).
Fieldwork Student Manual
updated 1/2014
4
Students in Nebraska that are required to have a drug screen may schedule an
appointment with Laura Byrd at Midlands Testing Service (402-658-1122). The office
is located at 8011 Chicago Street.
Students in Alaska that are required to have a drug screen may schedule an
appointment with Beacon Occupational Health & Safety Services, Inc. They can be
reached at (907) 222-7612.
Students need to work with Student Health and the Office of Academic and Student
Affairs (OASA) to ensure compliance with health requirements. For further
information on this policy: http://spahp.creighton.edu/departments-offices/academicand-student-affairs/policies-procedures

Policy on Student Compliance with Technical Standards for Occupational
Therapy:
The Doctor of Occupational Therapy education program in the School of Pharmacy
and Health Professions at Creighton University prepares occupational therapists to
serve as primary providers of occupational therapy care. In order to function as a
clinical occupational therapist, an individual must be able to meet certain physical,
emotional, intellectual and communication expectations for performance.
Occupational therapy education requires the accumulation of scientific knowledge as
well as the simultaneous acquisition and demonstration of psychomotor skills,
cognitive skills and professional attitudes and behaviors. The faculty is committed to
an educational environment where students may develop emotionally, spiritually,
socially and cognitively.
Technical standards must be met with or without reasonable accommodations
consistent with the Americans with Disabilities Act (ADA). The School is committed
to enabling students with disabilities to complete the course of study of the OTD
Program by means of reasonable accommodations consistent with the ADA.
Technical standards are necessary to create specific expectations for student
performance in the classroom, laboratory and clinical education environments. The
purpose of technical standards is to delineate the psychomotor skills, cognitive skills
and professional attitudes and behaviors deemed essential for matriculation into,
continuation in and completion of the educational program.
Observation/Sensory
Students must have sufficient visual abilities to be able to observe and interpret
patients/clients accurately. They should also possess functional tactile and
proprioceptive skills and abilities necessary to perceive and synthesize inputs during
patient/client interaction, evaluation, and treatment.
Communication
Students must demonstrate effective verbal and written communication with patients,
family members/caregivers, faculty/staff, fieldwork preceptors, payers, elected
officials, members of the healthcare team and others. They must demonstrate
appropriate communication with people of different ages and genders, with diverse
physical, cognitive and emotional abilities, and from different cultural, ethnic, racial,
socioeconomic, and religious backgrounds and lifestyles. Students must demonstrate
the ability to use therapeutic communication and a client centered approach. They
must display adequate English language skills in written and oral communication.
Fieldwork Student Manual
updated 1/2014
5
Motor
Students must display adequate motor skills to provide safe, efficient, and effective
occupational therapy treatment. Examples of skills requiring motor ability include
sitting tolerance, splint or assisted technology fabrication, computer usage,
performing transfers and assisting with bed mobility, and providing range of motion
and strengthening activities. The motor abilities required include adequate gross and
fine motor function, vestibular function, strength, and functional usage of the sensory
system.
Intellectual/Conceptual
Students must demonstrate problem solving throughout the didactic and experiential
components of the program. This includes the ability to interpret information from
multiple sources (written, verbal, environmental, interpersonal, etc.), carry out
instructions in a timely manner, and understand and follow written instructions such
as policies and procedures. Therefore, the student must be able to read complex
material, and write in a way that is accurate, descriptive, free from errors and
consistent with guidelines or standards. Further, students must be able to apply
critical thinking processes in order to gather information, identify problems and
alternative plans of action. They must be able to make decisions spontaneously in
"on the spot" situations, pressure situations from high workload demands, and
variable time and environmental demands.
Behavioral / Social Skills / Professionalism
Students must possess sufficient emotional health to fully utilize their intellectual
abilities, exercise good judgment, adhere to ethical standards, complete patient care
responsibilities promptly, and relate to others with courtesy, compassion, maturity,
and respect for their dignity. Because occupational therapy education and practice
takes place in a large variety of settings, students must have the ability to participate
collaboratively as a (professional) team member, must be able to modify behavior in
response to feedback, and display emotional health when faced with changing
environments, clinical uncertainties, and stressful workloads that include multiple
concurrent demands and short deadlines. This requires the ability of students to be
aware of and appropriately react to their own emotional responses. In addition,
students must at all times maintain personal appearance and hygiene that is
appropriate for professional and classroom settings.
Attainment of Technical Standards
Inability to comply with these technical standards may result in course failure.
Applicants are encouraged to voluntarily discuss their disabilities with the Director of
Admissions and the Assistant / Associate Dean for Academic Affairs of the School in
order to consider and prepare for the accommodations that may be needed. After
enrollment, a student with a disability who wishes to request reasonable
accommodations may directly contact the Assistant / Associate Dean for Academic
Affairs of the School or the Creighton University Office of Services for Students with
Disabilities. Verification and documentation of the disability by a qualified
professional, such as a physician or psychologist, will be needed before reasonable
accommodations are made. Accommodations will not be considered reasonable if
they affect the substance of the occupational therapy educational program,
compromise the School’s educational standards, and/or negatively affect the safety of
students and/or other people, including patients, with whom they may come into
contact in the course of their studies. If accommodations are provided, this
information will be kept in strict confidence.
Fieldwork Student Manual
updated 1/2014
6
All occupational therapy applicants must review the technical standards described in
this document and perform a self-evaluation to determine if they are able to maintain
compliance with them. A signed copy of this form should be returned to the SPAHP
Office of Admissions signifying the standards have been read and certifying
compliance.
During orientation, all students signed a document that serves as testimony that the
student is in compliance with these standards and understands the responsibilities it
outlines. A student who is dismissed from the program and subsequently reinstated
must re-sign this document as testimony that the student is in compliance with these
standards.

Accommodations Process for Students with Disabilities: The School of
Pharmacy and Health Professions is committed to assisting students with disabilities
in accomplishing the academic mission of our programs. Students who believe
themselves eligible for accommodations under the Americans with Disabilities Act
should contact Dr. Paul Price, Assistant Dean for Academic Affairs for assistance in
accessing allowed accommodations. The Office of Academic and Student Affairs is
located in Room G 74 Criss III. The phone number of the Office is (402) 280-1147.
Accommodations for fieldwork experiences may be quite different from those used in
the classroom. For this reason, students should notify the Academic Clinical
Education Coordinator well in advance of a fieldwork experience so that the
accommodations process can be initiated in a timely manner.

Clinical Plan of Study: All students in the Creighton University Doctor of
Occupational Therapy Program are required to complete a Clinical Plan of Study
(CPOS) (see Appendix A) to assist them in exploring their future clinical education
plans and trajectory. The CPOS is a planning and counseling tool only, not a binding
contract, nor a guarantee of fieldwork placement.
Procedure: Students will initiate their Clinical Plan of Study during the fall semester of
their first year in the OTD program. As part of the Clinical Plan of Study, students will
first be asked to complete a learning style questionnaire and to review a Fieldwork
Practice Settings table and explanations. Students will then complete a Clinical Plan
of Study Questionnaire followed by the actual Clinical Plan of Study, indicating
potential practice settings that they may want to explore during their education in the
OTD program. Finally, students will be required to attend a 1:1 meeting with an
Academic Clinical Education Coordinator to review their Clinical Plan of Study
annually. The Academic Clinical Education Coordinator(s) and students are jointly
responsible for tracking the progress and completion of each student’s Clinical Plan
of Study.

Housing Accommodations during Clinical Experiences: Students must locate
and secure their own housing arrangements for each clinical experience.
Cancellations of placement will not be allowed based on a student’s inability to find
housing. In addition, it is the responsibility of the student to arrange housing that is
financially feasible during the clinical experience. The site files may contain
information about housing from the site and/or past students if it is available. In
addition, the Creighton University Alumni Relations can be very helpful in locating
alumni living near clinical sites. Contact Alumni Relations at 1-800-325-2830 or
http://spahp.creighton.edu/alumni for further details.
Fieldwork Student Manual
updated 1/2014
7

Personal Data Sheet: Complete a Personal Data Sheet for each Level I and Level II
fieldwork. (See Appendix B for a sample). Please note this starts with your Level IB
Fieldwork experience, students will not complete a Personal Data Sheet for Level IA
Fieldwork. These need to be typed and the completed form returned to the instructor
of record or Assistant Clinical Education Coordinator by the required due date. The
Personal Data Sheet is sent to the fieldwork site prior to the student’s arrival.

Safety Practices: Safety practices to protect the patient, yourself and other staff are
of the most urgent concern to all health professionals. It is your responsibility to
learn the safety and emergency policies and procedures of your fieldwork site,
including the policy on provision of CPR. Learn the location of fire extinguishers.
Use good body mechanics and positioning of media or activities to maximize safe
usage. Know what to do in the event of an emergency so that you will not contribute
to a preventable accident. Sites have the right to refuse and/or terminate the clinical
experience for any student who does not follow appropriate safety practices. Failure
to maintain proper safety practices for the fieldwork site may impact your
grade for fieldwork-related courses.

Incident Reporting: If a student gets injured, is involved in an accident, or is
exposed to blood/body fluids during a clinical education experience, appropriate
reporting needs to occur at the site according to site policies. Additionally, students
should complete an Incident Report form and file it with the University. This serves to
protect the student and allows for appropriate risk management analysis. The
Creighton University HR-24 Incident Report form can be found in Appendix Q and
also at http://www.creighton.edu/finance/riskmanagement/forms/index.php

Occupational Therapy Code of Ethics: This is required reading before and during
your fieldwork experience. Accountability for the knowledge and application of these
principles underlies your ongoing professional development. To view the American
Occupational Therapy Association (AOTA) Code of Ethics and Ethics Standards,
visit: http://www.aota.org/Practitioners/Ethics/Docs/Standards/38527.aspx.
If you encounter an ethical dilemma or issue while on fieldwork you have several
resources available to you. First, you should contact the Academic Clinical Education
Coordinator who is serving as the instructor of record for your fieldwork experience.
Additionally, ethics consults are available by contacting either Dr. Linda Gabriel
([email protected]) or Dr. Linda Scheirton ([email protected]).

Professionalism: A professional image is displayed through attitude, posture, tone
of voice, eye contact, appropriate grooming, hygiene and apparel and timeliness. As
a student therapist you represent the occupational therapy profession and Creighton
University. Most sites have written policies regarding patient/therapist interaction.
Continued contact with a patient/client outside of the clinical education environment is
considered beyond the scope of professional practice. You should maintain a
professional image with your clients, fieldwork educators and any other professional
with whom you have contact. Any questions or areas of concern regarding
student/patient interaction should be discussed with the fieldwork educator and
academic clinical education coordinator. Failure to maintain a professional image
may impact your grade for fieldwork-related courses.
Fieldwork Student Manual
updated 1/2014
8
Social networking through electronic media such as Facebook is a common habit of
many students and occupational therapists. The Office of Academic and Student
Affairs’ document entitled Professionalism Considerations for Online Social
Networking Usage outlines suggestions and considerations for use of electronic social
networking media: http://spahp2.creighton.edu/oasa/Polices,Procedures%20.aspx To avoid
any breaches of confidentiality, conflicts of interest and questionable unprofessional
behaviors, the Occupational Therapy Office of Clinical Education strongly
discourages students to engage in this type of social networking with any patients,
supervisors or co-workers during fieldwork experiences.

Professional Attire: Professional attire includes a student name tag; full-length
pants; shirts with sleeves; and closed-toe/heel shoes with socks. No undergarments
should be seen at any time (even when squatting, reaching overhead, etc.). Clothing
should not be tight-fitting or low-cut. A lab coat may be required by certain fieldwork
sites. We advise you not to wear jeans, sweatshirts, sandals or tennis shoes unless
the fieldwork educator approves of that attire. To ensure your safety, large earrings
and rings, or dangling necklaces are not allowed. Sites have the right to refuse
and/or terminate the clinical experience for any student who does not dress
appropriately. Sites have the right to request that a student follow a specific dress
code, which may include scrubs, khaki pants, polo shirts, or similar attire. Please
check site files and with your fieldwork educator to inquire if there are specific dress
code requirements for your site. The attire for fieldwork experiences is in accordance
with the dress code established by Creighton University’s School of Pharmacy and
Health Professions. Failure to maintain proper professional attire may impact
your grade for fieldwork-related courses.

Name Tag and Lab Coat: Positive identification of your student position is fulfilled
by wearing the Creighton University Occupational Therapy Student name tag. In
some settings (e.g., psychiatric units) it is advised that you cover your last name,
using tape or a piece of white paper. You should discuss this with your fieldwork
educator. In some hospital or clinical settings a lab coat may be required. You will
receive your name tag and lab coat at the Professionalism Ceremony during your first
semester of the program.

Initialing Notes: Since students are participating in an AOTA/ACOTE (Accreditation
Council for Occupational Therapy Education) requirement while in fieldwork, they are
designated as occupational therapy students or OTS. Creighton University’s position
is consistent with the guide to practice and the AOTA Roles document in which
occupational therapy students (OTS) are recognized as practitioners in training. The
degree (BSOT, MSOT, OTD, etc.) is recognition of the university, not AOTA.

Level II Fieldwork and Dates: Your Level II Fieldwork dates are set at least one
year in advance. This allows the Clinical Education Office and students to plan
accordingly. Students will not be excused from attendance in didactic course due to
travel time or request for time off following fieldwork experiences. Below are the
Level II Fieldwork dates for the next several summers. These fieldwork dates are not
flexible secondary to the limited number of weeks in a summer semester. If you are
planning life events such as family reunions, vacations and/or a wedding, you need to
work around these dates or take a leave of absence from the program to
accommodate your life event. If you prefer to take a leave of absence, you may
discuss this with Dr. Joy Doll, Vice Chair of the Department of Occupational Therapy.
Fieldwork Student Manual
updated 1/2014
9
Please refer to schedule on the Office of Academic and Student Affairs website for
verifying these dates: http://spahp.creighton.edu/departments-offices/academic-and-student-affairs
2014 – May 19 – August 8 (Level IIA and Level IIB)
2015 – May 18 – August 7 (Level IIA)
September 21 – December 11 (Level IIB)

Professional Rotation Dates: Your Professional Rotation dates are set at least one
year in advance in accordance with the fall semester dates. This allows the Clinical
Education Office and students to plan accordingly. Following are the Professional
Rotation dates. These dates are not flexible because of deadlines to meet for
graduation requirements. If you are planning life events such as family reunions,
vacation or a wedding, you need to work around these dates or take a leave of
absence from the program to accommodate your life event. If you prefer to take a
leave of absence, you may discuss this with Dr. Joy Doll, Vice Chair of the
Department of Occupational Therapy. Please refer to schedule on the Office of
Academic
and
Student
Affairs
website
for
verifying
these
dates:
http://spahp.creighton.edu/departments-offices/academic-and-student-affairs
Class of 2014 – August 18 – December 5
Class of 2015 – August 17 – December 4
Class of 2016 – January 11- April 29
Class of 2017 – January 9 – April 28

Hooding and Graduation Dates are tentatively scheduled for:
Class of 2014 – December 19 (Hooding) & May 17 (Graduation)
Class of 2015 - December 18 (Hooding) & May 16 (Graduation)
Fieldwork Student Manual
updated 1/2014
10
LEVEL I FIELDWORK
The following process and guidelines apply to Level IB, Level IC, and Level ID
Fieldwork experiences.
Level I Fieldwork Placement Process:
Students will submit specific site preferences electronically in the clinical education
Share Point site in rank order. These sites will be contacted and availability will be
determined. If more than one student requests a specific site, names will be drawn. If
none of the requested sites are available for a student, that student will be placed locally
based on his or her desired practice area. Students should consider varying the practice
area from previous fieldwork experiences and may be counseled by the ACEC in this
regard.
Once the placement process (i.e., contacting sites) has been initiated, students may not
make changes to their Level I preferences.
The process for Level I placements is different from Level II placements. During the
Level II placement process, the Office of Clinical Education asks sites for advanced
reservations. During the Level I placement process, sites are contacted only after
students request them so that requests are not sent to the 340+ sites in our database.
This takes into account time, cost, site relationships, etc.
The ACEC reserves the right to modify the process based on extenuating circumstances.
If this happens, the ACEC will discuss this with the specific student(s) involved.
Once a student is placed, the Assistant Clinical Education Coordinator notifies sites
receiving students and sends a Level I student packet to each site. The student packet
includes students’ personal data sheet, student performance evaluation and appropriate
Level I assignments and guidelines. Students receive notification of their site, as well.
The dates of the fieldwork have been negotiated with the site and the University. Any
missed time must be made up by the student, at the convenience of the site. Students
are not to re-arrange dates of fieldwork assigned without the specific approval of the
instructor of record for the fieldwork course beforehand.
Level I Fieldwork Evaluation Process:
All evaluation forms must be received by the due date on the syllabus. At the conclusion
of the fieldwork experience, the fieldwork educator at the site will complete the Level I
Student Performance Evaluation (see sample in Appendix D) and the student will
complete the Level I Student Evaluation of Fieldwork (see sample in Appendix E) and
meet to review the evaluations. All evaluation forms require both the signatures of
the fieldwork educator and the student. It is the responsibility of the student to assure
the evaluation forms have been completed and returned to the instructor of record. The
evaluation forms may be hand delivered, faxed, or mailed to the IOR by the student.
It is strongly recommended that both the student and the fieldwork educator make
copies of both evaluations in case something is lost in the mail.
Guidelines for Level I Fieldwork
Fieldwork site Responsibility:
Fieldwork Student Manual
updated 1/2014
11
The clinical fieldwork site provides opportunities for education and experience with
selected patients, under supervision.
Supervisory Responsibilities:
 Provide the student with the opportunity for observation and/or assistance in patient
evaluation, treatment planning and/or implementation.

Make patient records accessible to the student.

Provide ongoing feedback regarding the student's performance.

Allow the student the opportunity to compare information presented in the academic
setting with experiences gained in the clinical setting.
Student Responsibilities:
The successful completion of a clinical experience is required to achieve a satisfactory
grade in all level I fieldwork experiences. The student should demonstrate responsibility
for independent learning by asking questions of, and initiating discussion with the
fieldwork educator. Students are expected to interact in a professional manner with all
clients, supervisors, and other professionals encountered during the fieldwork
experience. Failure to act professionally could result in failure to achieve a
satisfactory grade in the clinical experience. Any student whose clinical competence
and/or attitudes and behaviors are sufficiently deficient or inappropriate so as to warrant
removal from a clinical site prior to the completion of the clinical education experience
will receive a failing (F) or unsatisfactory (UN) grade for that experience. Please see the
complete
policy
for
Clinical
Guidelines
here:
http://spahp.creighton.edu/sites/spahp.creighton.edu/files/basicpage/file/Clinical%20Guidelines.pdf
Student Responsibilities for Level I Fieldwork:
1. Students will be instructed to contact their fieldwork educator early in the semester
after thoroughly reviewing the site file, including the Fieldwork Data Form. The
Fieldwork Data Form contains site requirements, expectations and policies. Students
are then to confirm where to meet the fieldwork educator on the first day, parking,
dress code, and the hours of fieldwork. Additionally, students should ensure they
have all necessary immunizations, including an influenza shot, background checks,
etc. needed to complete fieldwork at the site. It is highly recommended that you
take your health records with you on each fieldwork experience. Again, it is the
student’s responsibility to complete all site requirements prior to starting any clinical
experience, as mentioned in the Experiential Education Participation Policy (see p.
4). It would also be helpful to inquire about typical clinical conditions seen,
assessments used, or any other reading/research that could be done prior to arriving
at the fieldwork site that would prepare the student for a successful experience.
2. Transportation is the responsibility of the student. Some clinical sites may be further
away and students are responsible for arranging and/or providing their own
transportation. Travel days are considered the Saturday and Sunday prior to the
start date of fieldwork and the Saturday and Sunday following the end date of
fieldwork. Students are still responsible for all course work and related activities the
week before and week following fieldwork.
Fieldwork Student Manual
updated 1/2014
12
3. Failure to complete the required fieldwork time may result in re-scheduling the
placement or in a failing grade. Because of the short period of time students are
assigned, it is advantageous to maximize the learning experience to prepare as a
developing professional. Students should make the most of the time spent at the site
by being punctual, demonstrating educational curiosity and integrating observations.
Unavoidable absences may occasionally arise, and making these up are the
responsibility of the student. Refer to the course syllabus for more information.
4. Students should arrive at the site in time to find parking and be in the office or work
area of the fieldwork educator by the appointed starting time. If an emergency
arises, students should call to inform the fieldwork educator.
5. Students should expect to remain at the facility until the departure time designated by
the site. Requests to leave early will not be considered appropriate conduct.
6. Student participation with clients during a level I fieldwork begins with observation of
the clinical interaction and progresses to some portions of hands-on care. Any
participation with a client is at the discretion of the fieldwork educator. If a student
does not feel comfortable participating with a client, he or she needs to communicate
his or her comfort level directly with the fieldwork educator. However, fieldwork
educators may offer hands-on teaching opportunities and students should take full
advantage of these.
7. Students should send a letter of appreciation to their assigned fieldwork site and/or
fieldwork educator within one week of their last day at the site. (See Appendix N for a
sample thank you letter.)
Fieldwork Student Manual
updated 1/2014
13
LEVEL II FIELDWORK
Assignment Process:
Placement for Level II Fieldwork is the responsibility of the Academic Clinical Education
Coordinator(s) and the Assistant Clinical Education Coordinator. Students have the
opportunity to visit with the Academic Clinical Education Coordinator(s) to clarify the
placement process or discuss information about a particular site. The quickest and most
efficient manner of communicating with the Academic Clinical Education Coordinator(s)
is to make an individual appointment via Outlook.
A fieldwork placement is guaranteed by the University however we do not ensure
geographic or other preferences. Students are strongly encouraged to plan and
discuss finances, housing possibilities and travel arrangements with their family
prior to completing the placement process. There is no perfect placement process
as the matching of fieldwork sites to students is a very complex and dynamic operation.
The Clinical Education Seminar Course in your 2nd year will specifically address the
Level II Fieldwork assignment process.
Please note: Pediatric fieldwork sites are available for Level IIA fieldwork students
in the Class of 2016 and Level IIB fieldwork students in the Class of 2015. This is
due to the fact that students are required to complete all pediatric courses prior to
engaging in fieldwork.
ABCs of FIELDWORK PLACEMENT PROCESS
A. Listing of Available Sites
An advanced reservation request is sent to all sites that provide clinical experiences for
Level II students (~341 sites). A listing of available sites is generated from these as they
are returned from the clinical sites. Early in the fall semester a listing of available sites
for the following summer will be available on the Clinical Education SharePoint database,
which can be located here: http://otclined.creighton.edu. Please note this list is subject
to change.
Some sites do require a name to reserve a slot and are identified as “1st come, 1st serve”
slots, these opportunities will be shared with students using Creighton University email
addresses. Interested students will have up to one week or until the provided deadline to
respond to the email before guaranteeing the slot with a student name. If multiple
students express interest in a site, a randomized drawing of names will be held for this
slot. If a student is placed at a site in this manner they will be removed from the general
placement process that occurs during the fall semester. Some sites now require an
application process and interview. This information can be accessed through the Clinical
Education database or the Academic Clinical Education Coordinator(s) will let you know
which sites require this process as it may take place prior to the placement process.
B. Placement Process
The Clinical Education Office reserves the right to decide the placement process
that will be used.
The placement process occurs early in the fall semester for OTD2 students. The OTD2
students are given directions for the placement process in the Clinical Education
Seminar Course, during FW meetings, via email, and through written communication in
student mailboxes.
Fieldwork Student Manual
updated 1/2014
14
Students choose 10 sites for FW placement from the available sites listing and submit
their choices (see appendix F) to the Academic Clinical Education Coordinator(s) by the
assigned deadline. When more than 1 student identifies the same site, students are
randomly selected for that site. If students do not receive one of their first 10 choices,
they will meet with the Academic Clinical Education Coordinator(s) to discuss their
options. If you fail to meet the deadline for site selection, you will be placed after all
other students are placed at their fieldwork site.
When submitting your preference sheets electronically, here are some tips:
1) It is highly advisable that you do not put all Omaha sites. This increases the
likelihood you will end up without a site at the end and need to select from
remaining sites.
2) If you do not want to go to a site, do not put it on your list. You may be placed at
any of the ten slots you list.
3) If you put a site on your list that offers multiple options then include the practice
setting (i.e. rehab, inpatient acute, etc.) you prefer. However, the Clinical
Education Office cannot guarantee that you will be placed in the practice setting of
your choice.
There may be extreme extenuating circumstances that require exceptions to the above
placement process. The Academic Clinical Education Coordinator(s) reserve(s) the right
to place a student at a site based on what is the best supported environment for a
student’s successful completion of a fieldwork experience. Strict confidentiality and
ethical standards are maintained in each case.
C. Completion of Placement Process
Letter of Hardship indicating an Extenuating Circumstance Request
A student who believes that a need exists to request a placement in a specific fieldwork
location, must complete a formal letter of hardship in writing and submit it to the
Department Chair and the Director of Clinical Education a minimum of 2 weeks prior to
the fieldwork preference list due date. Circumstances that may warrant a formal request
include: a verified medical need or a verified family member illness. A student that
submits a formal letter of hardship will be notified whether or not their request will be
considered. This will allow students to plan accordingly when submitting a preference
list. Students must keep in mind that prior to a student’s fieldwork portion of the
curriculum being scheduled and confirmed; student-initiated requests for extenuating
circumstances may have significant implications.
Fieldwork Placement Change Requests (Post placement process)
Once a student has chosen a site, and the site has been notified, the Program and
student are bound to honor that commitment. In the case of extenuating circumstances,
requests for change of the education fieldwork placement may be submitted to the
Director of Clinical Education for consideration. We encourage sites to honor their
commitments as well, but we acknowledge that changes in the clinical environment may
necessitate site cancellations. A Leave of Absence (LOA) will likely be recommended,
and should strongly be considered, in many change-request cases.
Fieldwork Student Manual
updated 1/2014
15
Change requests will only be evaluated for the following reasons: (An evaluation of
a valid change request may or may not result in a change in fieldwork placement)
Health:
Personal: Note from physician verifying illness or hospitalization will be required
 Verified illness, hospitalization, or surgery that cannot be rescheduled to a nonconflicting time
Immediate Family Member: Note from physician, as appropriate, will be required
 Immediate family members (student’s spouse, parents, siblings, children,
grandparents, father/mother-in-law, son/daughter-in-law, or grandchild) with
critical illness
Pregnancy: Note from physician verifying pregnancy with approximate due date or
activity restriction will be required
 Pregnancy with risk factors and/or imminent due date
Emergent Personal Situation: Appropriate documentation may be required
 Serious situations emergently affecting ability to complete experience (e.g.,
divorce, safety issues)
Change requests will not be evaluated for the following reasons: Students must
plan ahead prior to submission of fieldwork preference list to ensure, to greatest extent
possible, that personal circumstances (including those listed below) pose no impediment
to the completion of confirmed experiences.
Child/Dependent Care:
 Back-up childcare/dependent care needs to be planned for and obtained in
advance
Travel to Rotation Site:
 Students are responsible for making arrangements for appropriate travel and
transportation, i.e. relocation to the fieldwork placement site and transportation
during the fieldwork experience.
Housing Availability:
 Students are responsible for making housing arrangements during fieldwork.
 Back-up housing needs to be planned for and obtained (e.g., long-term hotel,
apartment leasing)
 Students may contact their fieldwork educator and the School’s Alumni Relations
office for housing suggestions and assistance.
Relocation:
 Changes in fieldwork schedule due to personal or family relocation. The only
exception to this is in the case of the mandatory deployment of a student who is
actively serving in the U.S. armed forces
Post-Graduate Plans:
 Change in focus/interest, potential job opportunities, or residencies after
graduation
NOTE: Any special circumstance (e.g. medical needs, family member illness, etc.)
necessitating a request for a specific fieldwork placement may be considered on a
case-by-case basis.
Fieldwork Student Manual
updated 1/2014
16
Contacting Fieldwork Sites:
Students are NOT permitted to contact their site until permission is granted from
the Clinical Education Office after all of the items below are completed.
Students are provided with their individual placement and contact name when the
placement process is completed. At that time, the student will sign the Assignment
Agreement Form (Appendix G) and return it to the Academic Clinical Education
Coordinator(s) by the specified date assigned. Once the Academic Clinical Education
Coordinator(s) and Assistant Clinical Education Coordinator have completed all the
fieldwork placements, a roster is posted on the Level II Fieldwork Preparation Seminar
and Level ID course websites which lists the facility address, fieldwork educator name,
phone number and dates of placement. The following packet of materials is then sent in
the spring prior to the student’s arrival to each site: course syllabus and confirmation
forms (Appendix H). Students are responsible for providing the fieldwork site with the
student’s personal data sheet (Appendix B), and any other documentation that the site
requires. The Fieldwork Performance Evaluation Form (FWPE) is electronic and
fieldwork educators will receive information regarding access and use of this form in the
first few weeks of the fieldwork experience. A copy of the FWPE form is included in
Appendix I.
After placements are complete, no changes will be made to the fieldwork
placement unless the site cancels, or the student fails to complete any prerequisites for OTD 481 or OTD 571. Students may not request a new placement
after the initial placement process.
Please note: Sites reserve the right to place students in a practice setting that is
conducive to learning, even if it is different from the anticipated practice area
noted during the site selection process. It is expected that students be prepared
to achieve entry-level competency in any practice setting.
Cancellation:
If a fieldwork placement is canceled, the student will be notified immediately and
alternate choices will be determined with the Academic Clinical Education
Coordinator(s). The Academic Clinical Education Coordinator(s) will review the student’s
initial site preference list to determine if any of the student’s original choices remain
available. If a site from the student’s original preference list is still available, the student
will be placed at that site. If the student’s original preference list has been exhausted,
the student will be provided with alternate choices. The alternate choices will be taken
from the advanced reservations that were not used during the original placement
process, also known as the remaining sites list. The student will choose a site or sites
from this list and the site(s) will be contacted to determine availability. If a site is
available, the student will be placed at that site.
Contracts & Facility Files:
Creighton University has contracts for occupational therapy fieldwork with approximately
341 facilities across the country. A contract/agreement between the site and Creighton
University must be signed by both parties before a student can be placed. Fieldwork
files of the various facilities are located in the Occupational Therapy Clinical Education
Database in SharePoint. For questions or concerns regarding the files, contact Mary Pat
Wearne. These electronic files contain evaluations of the site by previous students, the
fieldwork objectives as outlined by the facility, and general information if available about
the sites including: types of clients, dress code, hours, housing or meals provided, and
Fieldwork Student Manual
updated 1/2014
17
occasionally maps/brochures from the area. The ACECs strive to keep updated records
online, however, sites may update information at any time and should be the first point of
contact for clarification of site offerings once a student has been confirmed at a site.
Some sites provide examples of student assignments or student notebooks. Students
may make appointments with the Academic Clinical Education Coordinator(s) to gain
more details about particular sites.
Fieldwork Student Manual
updated 1/2014
18
SITE DEVELOPMENT
New Site Development:
The goal of site development is to obtain new sites that align with the curriculum of the
OTD program. The Clinical Education Office looks for quality sites that are congruent
with the curriculum at Creighton University and those who will be committed to accepting
Creighton students on a regular basis. The priority of the Clinical Education Office is to
ensure quality fieldwork sites, in a variety of practice settings, providing you with
continued optimal learning experiences.
Students are given the opportunity to contribute to development of a new site that would
be a benefit to Creighton University’s Occupational Therapy program, by submitting a
Site Recommendation Form (see Appendix O) which outlines how this particular site will:
a) meet the OTD program objectives,
b) provide an opportunity for future students, and
c) further enhance the fieldwork program by offering a quality experience.
The Clinical Education Office is open to developing additional sites that are congruent
with our curriculum and represent a variety of practice areas.
When students are interested in developing a site, they need to make an appointment to
meet with the Academic Clinical Education Coordinator to discuss the process. Students
are not permitted to contact a site to solicit a fieldwork slot. Sites will not be developed
that will only accommodate ONE student’s needs and/or specific preferences,
including geographical location. A student contacting a site should only obtain
general information needed to complete the site development form.
Every Site Recommendation Form will be reviewed by the Clinical Education team. The
Clinical Education team reserves the right not to pursue a site should they feel that it
doesn’t meet the OTD program objectives and/or enhance the clinical education program
or the practices of the facility are not congruent with the curriculum at Creighton
University. Should a site inquire if a student would like to reserve a slot, the student
should refer that site to discuss this with the Academic Clinical Education Coordinator(s).
If a site suggested by a student is developed for the OTD program, that site is made
available to all students.
Procedure for Site Development:
1. Identify source of site development and complete initial site screen
1.1. Site initiates contact with Creighton University
1.1.1. ACEC does preliminary research on site and discusses with clinical
education office for initial screening
1.1.2. ACEC calls or emails site for screening and completes Site Development
Report
1.1.3. ACEC shares report with clinical education office to reach consensus on
whether to pursue contract
1.1.4. If decision is made to decline site development, ACEC contacts site to
notify
1.1.5. If decision is made to pursue site development, move to step 2
1.2. Student expresses interest in site development
1.2.1. Student completes Site Recommendation Form (see Appendix O) and
returns to an ACEC
Fieldwork Student Manual
updated 1/2014
19
1.2.2. ACEC shares form with clinical education office to reach consensus on
whether to pursue contract
1.2.3. If decision is made to decline site development ACEC completes Site
Recommendation Form, providing rationale for student in writing
1.2.4. If decision is made to pursue site development ACEC completes Site
Recommendation Form, notifying student of decision, and moves to step
1.1.2 above
1.2.5. ACEC notifies student of final outcome of site development
1.3. ACEC/Faculty expresses interest in site development
1.3.1. ACEC or other faculty shares rationale for site development with clinical
education office for initial screening
1.3.2. Clinical education office reaches consensus on whether to pursue site
development
1.3.3. Follow steps 1.1.2 above
1.3.4. ACEC notifies faculty of final outcome of site development
2. Arrange site visit and/or further in depth phone call to document congruency of site
with curriculum
2.1. Level I site
2.1.1. ACEC completes visit/phone conversation as able prior to student(s)
participating in fieldwork at site
2.2. Level II site
2.2.1. ACEC completes visit/phone conversation as able prior to student(s)
participating in fieldwork at site
3. ACEC shares results of site visit with clinical education office
3.1. If consensus is to pursue contract move to step 4
3.2. If consensus is to decline contract development, ACEC contacts site to notify and
shares outcome with interested parties
4. Develop contract
4.1. Once completed, ACEC shares outcome with interested parties
4.2. Fieldwork site is available to all students, regardless of who initiated the site
development
5. All above mentioned forms will be retained by the Assistant Clinical Education
Coordinator
Fieldwork Student Manual
updated 1/2014
20
LEVEL II FIELDWORK EVALUATION PROCESS
During your Level II Fieldwork experience, you will be required to:
1. Participate in online discussions throughout the experience. Reflective discussions
are designed to assist students in their learning process and provide useful
information in determining student progress prior to the mid-term and final
evaluations. Failure to complete your discussion will result in an incomplete grade in
OTD 481 or OTD 571 until you complete a make-up discussion group or an
alternative assignment as determined by the instructor of record.
2. Additional assignments are listed in the OTD 481 and OTD 571 course syllabi.
3. Individual fieldwork sites may have site specific assignment requirements, and
students should follow the deadlines provided by the site.
4. Complete the Student Evaluation of Fieldwork Experience Form (see Appendix I)
during the last week of the placement. The fieldwork educator completed the AOTA
Fieldwork Performance Evaluation (FWPE) for the Occupational Therapist
electronically in SharePoint. Students should allow enough time to thoughtfully fill out
this form -- the information is very useful to the Clinical Education Office, to the
Creighton Occupational Therapy Curriculum Committee, The Creighton Occupational
Therapy Assessment Committee, and to future students considering this fieldwork
site/facility. Students are advised to collect data to complete the Student Evaluation
of Fieldwork Experience Form beginning the first week of fieldwork. Students will
also have the option of completing an additional one page document to report
information regarding a site to only the Academic Clinical Education Coordinator(s).
This form will be made available on the fieldwork course website and should be
reserved only for concerns students have regarding a site that they do not feel
comfortable sharing with the fieldwork educator through the Student Evaluation of
Fieldwork Experience Form (SEFWE).
It is strongly advised that both the student and fieldwork educator make a copy
of both evaluations for their records.
5. The AOTA FWPE for the Occupational Therapist is used to assess students in Level
II Fieldwork. The minimum criterion scores are listed on page 2 of the FWPE. It is
recommended that the FWPE be used as a tool for communication to facilitate
professional growth as well as for evaluating performance. Students need to review
this form prior to fieldwork. Students are encouraged to complete the FWPE on
his/her performance as a comparison to what the fieldwork educator scores reflect at
both midterm and final review. Students should clarify with their fieldwork educator
any questions regarding use of the FWPE.
6. It is a requirement to complete online course evaluations for OTD 481 and OTD 571.
7. The final responsibility for your grade assignment rests with the Academic Clinical
Education Coordinator(s). The Academic Clinical Education Coordinator will record a
grade of Satisfactory/Unsatisfactory. The grade is determined by achievement of a
minimum score on the FWPE, student attendance, active participation in online
discussion boards, and satisfactory completion of all other required assignments as
stated in the course syllabi for OTD 481 and OTD 571. The student MUST score a 3
or 4 on items #1, 2, & 3 on the FWPE in order to pass the Level II FW course. The
student must ALSO achieve an overall minimum score of 122 on the FWPE to
pass.
Fieldwork Student Manual
updated 1/2014
21
8. Any student whose clinical competence and/or attitudes and behaviors are sufficiently
deficient or inappropriate so as to warrant removal from a clinical site prior to the
completion of the clinical education experience will receive a failing (F) or
unsatisfactory (UN) grade for that experience. Please see the complete policy for
Clinical Guidelines here:
http://spahp.creighton.edu/sites/spahp.creighton.edu/files/basicpage/file/Clinical%20Guidelines.pdf
9. Any student who earns a failing grade has the right to appeal the grade. Please see
the Scholastic Standing policy here:
http://spahp.creighton.edu/sites/spahp.creighton.edu/files/basicpage/file/Scholastic_Standing%20Policy.pdf
10. If the failing grade is appealed and overturned, the student may continue to progress
through the subsequent coursework.
11. If the failing grade is upheld, the student must successfully complete a clinical
remediation course, free of tuition. This will delay a student’s anticipated graduation
date.
12. Upon successful completion of the clinical remediation course, the student will be
required to successfully complete a Level II experience and then progress through
the rest of the curriculum sequence.*
13. If a student fails a Level II course and then fails the clinical remediation course, the
student will have two failing grades and will be dismissed from the program.
14. A student must earn a minimum total of 1144 from the combined Level IIA, Level IIB,
and NBCOT practice exam scores in order to pass the Competency course.
15. A student that earns a failing grade in the Competency course taken concurrently
with Level IIB fieldwork may NOT progress to his/her Professional Rotation
experience until a passing grade is achieved in the Competency course.
* Please note: A student may not progress to any other coursework, didactic
or clinical, until the successful completion of the clinical remediation course
and repeated Level II experience. It is important to recognize that this will
change the student’s anticipated graduation date.
Absence Policy:
Occupational Therapy students need to complete a minimum of 24 weeks of Level II
fieldwork to meet the Accreditation Council for Occupational Therapy Education
(ACOTE) standards for entry into the profession and to contribute to graduation
requirements of the University.
 Students
expected
fieldwork
student’s
do not receive any time off during a clinical experience. Students are
to treat the fieldwork experience as new employment. If a student’s
educator observes a holiday or an internal department closing, the
schedule is determined by the fieldwork educator. If Creighton University
Fieldwork Student Manual
updated 1/2014
22
is closed, but the fieldwork site is open, the student must default to the fieldwork
site’s schedule.
 Requests for vacation days ARE NOT APPROPRIATE during your Level II Fieldwork
experience(s). If extenuating circumstances prevail, you must gain approval, via
email, from your Academic Clinical Education Coordinator (ACEC) at least TWO
weeks prior to the date requested off and communicate with your fieldwork educator
to determine how to make up for missed days.
 In the event that a student absence is unavoidable, Creighton University suggests
that all student requests for personal leave be negotiated directly with their fieldwork
educator. Examples of acceptable reasons for leave are illness, family
emergency, medical appointments, funerals, or a child’s illness. Students must
inform, in writing, the ACEC that is his/her instructor of record, indicating the absence
date(s), reason for absence, and confirmation of communication with his/her fieldwork
educator immediately.
 The fieldwork educator has the right to request that a student make up any missed
time for successful completion of the Level II fieldwork experience.
Site hours for clinical affiliation are not negotiable. The hours of the affiliation are set by
the facility. The weekly schedule will be determined by each fieldwork educator and/or
site. Some centers require occasional evening or weekend hours. You may be expected
to work 4 (10 hour) days as required by your fieldwork educator. Some fieldwork
educators work different schedules such as Tuesday-Saturday. You are expected to
maintain the same work schedule as your fieldwork educator.
Any changes to the dates for the fieldwork experience must be approved
and documented in writing by the ACEC and the Fieldwork Educator before the
start of the fieldwork experience. Approval of any changes must be granted by the
ACEC prior to requesting a change of date with the Fieldwork Educator/Fieldwork Site.
Students are expected to fully participate in the coursework on the course start date
following a Level II experience. Students may not request an absence, approval to view
an ECHO capture, or any other form of inactive participation. Fieldwork experiences are
completed on the Friday of week 12, unless arrangements were previously negotiated
(see above regarding changes to fieldwork experience dates). Students will need to
schedule travel plans with course start/stop dates in mind.
Fieldwork Student Manual
updated 1/2014
23
Preparation for your first Level II Fieldwork (OTD 481) will be covered in OTD 460 and
461Some requirements include:
1.
Students must update online competency quizzes for Universal Precautions/Blood Bourne
Pathogens and the Health Insurance Portability and Accountability Act (HIPAA) before beginning
Level II fieldwork rotation.
2.
Read and be familiar with:
a. The AOTA Principles of Occupational Therapy Ethics
b. The Department of Occupational Therapy Absence Policy for Level II Fieldwork
c. Universal Precautions for Occupational Therapy Services
d. Student fieldwork file for important information about the center, especially the dress code
and the behavioral objectives
e. The School’s policy on Requirements for Participation in Experiential Programs
3.
It is strongly recommended that each student write a letter or email their fieldwork site four to
six weeks before the beginning date to confirm arrangements. The letter must be typed
and professional in appearance. (See Appendix M for a suggested outline for this letter.)
Students should send a copy of the letter to the instructor of record and maintain a personal
copy. Many fieldwork educators now have email access and an email letter is an acceptable
form of communication. Please be aware that your clinical instructor may take several days to
respond by e-mail due to their clinical schedules.
4.
Financial arrangements should be made that will enable students to devote their time and
energy to the demands of clinical training without needing to work during fieldwork. The OT
department strongly discourages students from employment outside the Level II
Fieldwork hours.
5.
Students must be eligible to register for Level II Fieldwork prior to leaving campus. Your
compliance with health requirements of the University and your Level II site is required before
you are able to register for your Level II Fieldwork. Failure to comply with the health
requirements could result in a delayed start date for your Level II Fieldwork.
6.
Students are responsible for locating internet access during their Level II Fieldwork rotations.
Students are also expected to check their Creighton University email account and course
website on a weekly basis minimum. The instructors will communicate with students via your
Creighton University email account and the course website.
7.
Professional liability insurance and Worker’s Compensation for Level II Fieldwork is provided by
Creighton University. A copy of the liability insurance is available from the Assistant Clinical
Education Coordinator (see Appendix P)
Fieldwork Student Manual
updated 1/2014
24
Student’s Responsibilities during Level II Fieldwork:
1. Notify the Academic Clinical Education Coordinator(s) of any problems with scheduled dates for
fieldwork.
2. Provide the Academic Clinical Education Coordinator(s) with a current phone number prior to
leaving campus for the summer.
3. Read and be familiar with the fieldwork site’s student objectives, manual and/or other information
provided.
4. Keep notes about the types of clients seen, assessments and treatment techniques used. This
information will be helpful when filling out the Student Evaluation of the Fieldwork Experience form
at the end of the fieldwork experience.
5. Report any incident/accident, involving you and/or a patient/client, to the Academic Clinical
Education Coordinator following notification of the fieldwork site and the fieldwork educator. An
Incident Report should also be filed with the University.
6. Notify the fieldwork educator of any difficulties encountered during fieldwork. The student should
ask questions, offer alternatives, and problem solve to help resolve difficulties. The student
should not put off approaching his/her fieldwork educator; a delay in resolving difficulties cannot
be afforded.
7. Call the Academic Clinical Education Coordinator(s) if:
a. There is a problem you have not been able to resolve.
b. Your performance is at risk of not passing.
c. Support or feedback is needed.
d. You have incurred any accident, injury or event that impacts your ability to participate in your
fieldwork experience.
Most sites will allow students to use their phones, email or faxes to contact the University; however,
permission should be obtained first. If it is necessary to communicate via U.S. mail, letters can be
addressed to the Academic Clinical Education Coordinator, Creighton University, Occupational
Therapy Department, 2500 California Plaza, Omaha, NE 68178. If a student feels it is necessary to
talk away from the facility, they can call and leave a message for the Academic Clinical Education
Coordinator with an evening number. If there is even the possibility of a major problem, the student
should contact the Academic Clinical Education Coordinator immediately.
8. Provide the fieldwork educators with feedback during the fieldwork experience. Students will be
required to complete online synchronous discussion board during the Level II fieldwork rotation.
These online discussions are designed to facilitate reflection and provide a form of support for
students while on fieldwork. Reflection and group discussion is an important part of developing
clinical reasoning skills.
9. Project a professional image and pay constant attention to confidentiality of clients and to safety
practices.
10. Upon completion of Level II Fieldwork, we strongly recommend that you send a thank you letter to
the OT Staff of your site (see Appendix N for an example).
Fieldwork Student Manual
updated 1/2014
25
WHAT TO EXPTECT DURING YOUR FIELDWORK
The fieldwork experience is a continuation of a lifelong learning process. You will undoubtedly experience
conflicting emotions when entering this period of professional growth. You will be eager to begin treating
actual patients in an authentic practice situation, but you may also be apprehensive and unsure about your
skills with patients. The mechanical aspects of a professional day are new and there is also the uncertainty of
forming new interpersonal relationships with other staff, patient/clients, and other students.
This should be a stimulating period when you, the student, can explore your own abilities. You will be
encouraged to demonstrate resourcefulness, expected to be inventive with original ideas and to be able to act
upon them, and to be creative in your approach to clinical problems. It will appear that the clinical experience
is a very open setting - receptive to new ways and ideas.
You are encouraged to be resourceful and original in your treatment approach, and these goals have to be
within the framework of the facility and the occupational therapy service program. This is your opportunity to
put what you learned in the classroom into action within the context of your fieldwork placement. You may be
one of many Level II fieldwork students who pass through the fieldwork site during the year. Consequently it is
not realistic to expect major program changes to accommodate you or your special interests. There will be
times when your interests may be accommodated, but admittedly there are gaps between a student’s idealism
and practice reality.
Because of the above, you may encounter difficulties while on your fieldwork experience. Stress can be said
to occur when an individual feels threatened and his or her adaptive mechanisms tend to collapse. It can be
both the threat itself and the person’s reaction to it. Not every student will experience difficulties. However,
for those who do, a discussion about the dynamics of clinical fieldwork now may minimize some of the future
problems and offer you possible alternatives for coping with the situation. We encourage you to use the
Fieldwork Environment Assessment Tool (FEAT) (Appendix K) to help problem solve challenging situations
during your fieldwork experience. The FEAT (Appendix K) will be provided to you during your OTD 479
course. Another resource used by the Clinical Education Office is the use of the Strength Finders Approach
(Buckingham, M. & Clifton, D.O (2001). Now, discover your strengths. The Free Press: New York.). The
Clinical Education website contains a Fieldwork Tool Kit with many helpful resources as well:
http://spahp.creighton.edu/node/2885. The School of Pharmacy and Health Professions also has access to Student
Success Counselors. The Student Success Counselors may be contacted at any point in the fieldwork
experience for a variety of reasons.
The fieldwork experience is a teaching-learning process. The basic components are the teacher, the learner,
and the setting in which learning takes place. You should begin to explore when starting the fieldwork what
setting characteristics can be conducive to your learning, and what behaviors of the fieldwork educator
facilitate this learning. Relatedness, dependency, integrative capacity, trust, doubt, confidence, expectations,
evaluations, rewards, coping adaptations and defensive adaptation, ambiguity, and role conflict are a few
terms related to the positive and negative aspects of fieldwork experience. An individual’s capacity to tolerate
stress depends on many factors including early emotional experiences, knowledge about his or her present
situation, motivation and techniques for withstanding tension, self-understanding and present alternatives.
Conflicts may arise and the therapist and student may assume defensive attitudes. Clinicians are human with
the attributes and faults that we all share. Your presence may be threatening because of your new knowledge
and penetrating questions. Reduction of defensive behavior and anxieties facilitates the learning process.
This reduction of stress will require a cooperative effort between you and the supervisor. Please contact your
Academic Clinical Education Coordinator(s) if you need assistance in dealing with fieldwork related stress.
Fieldwork Student Manual
updated 1/2014
26
UNIVERSAL PRECAUTIONS
The following barriers should be used by all health care workers. Each individual fieldwork site will
have universal precaution recommendations. You are required to follow the site’s universal
precautions. These barriers should be used in situations in which contact with blood and body fluids
is likely. These barriers include:
1)
GLOVES Gloves should be available at all times and should be worn when the possibility
exists of coming into contact with blood and body fluids, or mucous membranes; when
handling soiled items or surfaces. Gloves should be changed after direct contact with each
patient. Gloves should be worn when cleaning up blood or body fluid accidents in the clinic.
Gloves should be disposed in the proper container identified by the site.
2)
MASK AND PROTECTIVE EYEWEAR When doing an evaluation/treatment that is likely to
generate droplets or splashes of blood or body fluids, both a mask and protective eyewear
should be worn. In many instances, personal eyeglasses will provide adequate protection.
3)
GOWNS Usually not necessary, but should be worn when soiling of clothes with blood or body
fluids is likely; for example, working with burn patients at which time the protective barrier
would be an advantage to the patient and the therapist. At times gowns will be required
depending on a diagnosis including immunosuppressed patients or individuals with staph
(clarify here).
4)
SINGLE ROOMS Necessary for patients infected with airborne pathogens and for patients who
represent a risk for environmental contamination; for example, patients who have poor
personal hygiene or profuse bleeding. All occupational therapy-procedures will be conducted
in the patient’s room with necessary precautions listed in 1-3 above.
5)
AIRWAYS Pocket masks and ventilator bags must be accessible for use with ALL patients.
IN ADDITION TO THE ABOVE BARRIER PRECAUTIONS, THE FOLLOWING SHOULD ALSO BE
CONSIDERED AS PART OF UNIVERSAL PRECAUTIONS:
6)
PREGNANT WORKERS Require no special restrictions from patient care activities. No
susceptible worker (pregnant or not) should care for patients with Varicella, Herpes zoster, or
Rubella.
7)
INJURIES From sharps should be avoided.
All sharp injuries occurring during
evaluation/treatment requiring Universal Precautions should be reported immediately to
Occupational Medical Services and handled according to facility policy.
8)
EXPOSED EXUDATIVE LESIONS Weeping dermatitis occurring in a health care worker or
Fieldwork II affiliating student should be evaluated by the Occupational Medical Service.
EQUIPMENT HANDLING ALL testing/evaluation equipment, materials or nonexpendable
supplies that contact mucous membranes require disinfecting with an agent registered by the
EPA as a sterilant.*
9)
10)
ENVIRONMENTAL CLEANING ALL workers must wear gloves for cleaning an area following
use of universal precautions. Blood and body fluid spills require special cleaning. Visible
material should be removed unless the spill is large (in which case it is prudent to flood the spill
with a germicide before removal). After removal, the area should be cleaned with a
germicide.**
Fieldwork Student Manual
updated 1/2014
27
11)
LAUNDRY ALL linen soiled with blood or body fluids or from patients on isolation should be
placed in water soluble bags and then yellow linen bags.
12)
WASTE ALL waste soiled with blood or body fluids as well as waste from patients in traditional
isolation categories will be handled as medical pathological waste. ALL trash should be
transported with care and handled with gloves.
13)
DISHES from patients on UNIVERSAL PRECAUTIONS do not require disposable food trays.
14)
COMPLIANCE with these guidelines will be monitored by supervisors. Employees or students
identified as not being in compliance with these guidelines will be counseled and retrained.
Employees or students who are repeatedly identified as failing to comply with these guidelines
will be subject to disciplinary action.
NOTE:
*Bleach - 1:10 Bleach/Water Solution
** Betadine - 4 ppm; or 1 oz. to 20 gallons H2O
Wescodine - 75 ppm; or 3 oz. to 5 gallons H2O
Bleach solution is recommended for small spills and Wescodine for large spills in sink,
toilet, tub, or floor.
Fieldwork Student Manual
updated 1/2014
28
HIPPAA REGULATIONS
Health Insurance Portability and Accountability Act (HIPAA)
KEY POINTS TO REMEMBER ABOUT HIPAA
 HIPAA stands for Health Insurance Portability and Accountability Act
 Patients have a right to understand how their health information will be used and disclosed within the
facility they are receiving care & receive a notice of privacy practices
 Patients have a right to obtain and see a copy of their health records
 Patients have a right to expect that their health information will be used only for legitimate purposes &
a right to file a complaint if they believe their privacy rights have been violated
 Patients have a right to request restrictions to how their health information is used & disclosed
 There are both criminal & civil penalties for breaching privacy rights
 Clinicians are only to use or disclose patients’ health information for work-related purposes
 Keeping patients’ health information confidential is part of a clinicians’ job responsibility
 Confidential conversations do not occur where third parties may overhear them (elevators, cafeteria,
etc.)
 Names or other identifying information should not be used to identify patients in conversations or in
written assignments whenever possible
 Oral communications of patient information are limited to the minimum necessary to get the job done
 Telephone conversations related to a patient are conducted where they cannot be overheard
 If the patient is a minor, a healthcare worker can share information with the parent/guardian
 Always confirm the name of the third party that you are communicating with about a patient
 Patient information that is no longer needed is discarded in an appropriate container or shredded
immediately
 Patient information is not left unattended in any public area (photocopiers, fax machines, etc.)
 Patient files are never left in plain view and identifying information must be obscured
 Patient schedules are not left in public areas
 In general, use of computer based patient information is limited to the minimum necessary to get the
job done
 Health care workers cannot leave a computer unattended that they have logged into
 All students in healthcare covered entities must comply with HIPAA regulations
Protected health information (PHI) is the following list of 18 patient identifiers and is protected under
HIPAA regulations.
1. Names
2. All geographical identifiers smaller than a state, except for the initial three digits of a zip code if,
according to the current publicly available data from the Bureau of the Census: the geographic unit
formed by combining all zip codes with the same three initial digits contains more than 20,000
people; and [t]he initial three digits of a zip code for all such geographic units containing 20,000 or
fewer people is changed to 000
3. Dates (other than year) directly related to an individual
4. Phone numbers
5. Fax numbers
6. Email addresses
7. Social Security numbers
8. Medical record numbers
Fieldwork Student Manual
updated 1/2014
29
9. Health insurance beneficiary numbers
10. Account numbers
11. Certificate/license numbers
12. Vehicle identifiers and serial numbers, including license plate numbers;
13. Device identifiers and serial numbers;
14. Web Uniform Resource Locators (URLs)
15. Internet Protocol (IP) address numbers
16. Biometric identifiers, including finger, retinal and voice prints
17. Full face photographic images and any comparable images
18. Any other unique identifying number, characteristic, or code except the unique code assigned by
the investigator to code the data
Online resources:
 http://privacy.med.miami.edu/
 CMS HIPAA Web page http://cms.hhs.gov/hipaa/hipaa1/default.asp
 CMS HIPAA Online Assistance
http://cms.hhs.gov/hipaa/online/default.asp
 HIPAA Advisory Online
http://www.hipaadvisory.com
 Medicare HIPAA documents
http://cms.hhs.gov/medicare/edi/hipaadoc.asp
Fieldwork Student Manual
updated 1/2014
30
ENTRY-LEVEL PROFESSIONAL ROTATION
Each OTD student is required to complete a 16-week Professional Rotation as part of their
experiential learning. The placement process, experience and outcome objectives may be
dramatically different than prior Level II fieldwork experiences. Students will continue their personal
inquiry toward professional development during a two-semester trajectory process to construct their
Professional Rotation during the third academic year.
Students will consider various options of types of practice environment(s) and gather data in order to
select an environment for their Professional Rotation. The selected practice environment will serve
as the basis for locating specific site options for Student’s professional rotation and for designing a
personal development plan in preparation for the rotation.
Professional rotations in the OTD program offer students the opportunity to extend and refine
knowledge acquired in the curriculum and utilize it meaningfully as a means of critically analyzing
occupational therapy practice. Using the OTD curriculum design as a framework, students will
articulate a rationale for professional rotation site choice(s) that considers: (a) their own occupational
interests and needs; (b) the opportunities, limitations, requirements and needs of particular practice
environments; and (c) the potential contribution a professional prepared with an OTD degree can
make to such environments.
A separate student manual for the Professional Rotation process will be distributed to students in
OTD 460 and 461.
Fieldwork Student Manual
updated 1/2014
31
NBCOT AND TEMPORARY LICENSURE
NBCOT - National Board for Certification in Occupational Therapy
Students need to direct all questions
regarding the NBCOT registration exam to NBCOT




Students are responsible for the application process
Students should access the web page at http://www.nbcot.org for details
Students should request and refer to the NBCOT exam handbook
The Clinical Education Office is NOT responsible for arranging the NBCOT exam for
students. Any questions should be directed to the Occupational Therapy vice-chair, Dr. Joy
Doll at 402-280-5667.
TEMOPORARY STATE LICENSE
Students applying for a temporary state license need to closely review the state’s temporary license
rules. If you need proof of completion of the OTD program prior to your final transcript being available
you should:


Direct this request in writing to the Chair of the Occupational Therapy program.
Indicate in the request where the letter should be sent.
No letters will be issued until the written request and the evaluation forms from the professional
rotation are received. Multiple requests for such letters do not advance the process. The University
will make every effort to fulfill the written requests, but no guarantees are made regarding when the
letter will be mailed. Students may contact the Occupational Therapy Department secretary at (402)
280-1864 for more information.
Fieldwork Student Manual
updated 1/2014
32
APPENDIX A
CLINICAL PLAN OF STUDY
Fieldwork Student Manual
updated 1/2014
33
Clinical Plan of Study (CPOS)
Purpose & Overview: The Clinical Plan of Study (CPOS) is designed to assist you in exploring your future clinical education plans and
trajectory. As part of your OTD education, you will complete several clinical experiences to prepare you to be an entry-level
occupational therapist. Below are the purposes of each clinical experience followed by the breakdown of the different experiences that
are required in the OTD program.
Level I Fieldwork: introduction to clinical experiences, application of knowledge to practice, and development and understanding of
client needs
Level II Fieldwork: development of competent, entry-level generalists in the field of occupational therapy
Professional Rotation: development of competent occupational therapists with advanced skills in an individually defined area of practice
From: http://www.aota.org
OT1 Year
Spring: OTD 318 Level IA Fieldwork: Mental Health (throughout semester)
 focus on mental health practice in occupational therapy, skilled observation, documentation, and therapeutic use of self
Summer: OTD 390 Level IB Fieldwork: Physical Rehabilitation (1 week)
 focus on physical rehabilitation setting, client centered practice, occupation-based practice, clinical assessment,
documentation, and rapport building.
OT2 Year
Fall: OTD 490 Level IC Fieldwork: Pediatric or Selected Practice Setting (1 week)
 focus on evidence-based practice, clinical intervention, documentation, and advocacy
Spring: OTD 491 Level ID Fieldwork: Pediatric or Selected Practice Setting (1 week)
 focus on evidence-based practice, clinical intervention, documentation, and advocacy
Summer: OTD 481 Fieldwork Level IIA (12 weeks)
 application of student understanding of occupation; demonstration of professional practice, leadership, and entry-level
competency; personal and professional identity development
OT3 Year
Fall: OTD 571 Fieldwork Level IIB (12 weeks)
 application of student understanding of occupation; demonstration of professional practice, leadership, and entry-level
competency; personal and professional identity development
Spring: OTD 600 Entry Level Professional Rotation (16 weeks)
 self-directed experience that begins after the successful completion of the Professional Competency course; serves as an
opportunity for students to identify an area in which they wish to develop advanced skills; consider engaging in program
development, research, advocacy, academia, advanced clinical skills, administration/leadership, etc.
General Overview:
Step 1: Complete the VARK learning style questionnaire. Please see instructions below.
Step 2: Review the Fieldwork Practice Settings table and provided explanations.
Step 3: Complete the Clinical Plan of Study Questionnaire.
Step 4: Complete the Clinical Plan of Study indicating potential practice settings that you may
want to explore during the listed semesters. Include practice setting, whether you prefer a
local or nonlocal site (list city or state), and name of specific site (if known).
Step 5: Schedule a 1:1 meeting with your assigned Academic Clinical Education Coordinator
to review your completed Clinical Plan of Study. Campus students sign up on your assigned
ACEC’s office door. Alaska students please email assigned ACEC for an appointment. All
Fieldwork Student Manual
updated 1/2014
34
students, please submit your completed form electronically to the appropriate drop box prior to
your meeting time.
Step 1. The VARK
The VARK will be helpful in understanding your own learning style and in guiding you in completing
your clinical plan of study. If you’ve previously taken the VARK, it is suggested that you re-take it to
assess if your learning style has changed.
Go to the following website and complete the 16 question VARK learning style
inventory.http://www.vark-learn.com/english/page.asp?p=questionnaire
Upon completing the VARK, please answer the following 2 questions:
1. According to the VARK, what is (are) your learning preference(s)? (e.g. visual, aural, read/write,
kinesthetic)
2. Please briefly reflect on your learning preference results.
Step 2. Fieldwork Practice Settings
Hospital-based
Community-based
School-based
Other
In-Patient Acute
Pediatric
Community
Behavioral Health
Community
Older Adult
Community Living
Early Intervention
Nontraditional
In-Patient Rehab
SNF/SubAcute/Acute LongTerm Care
General Rehab
Outpatient
Outpatient Hands
Pediatric
Hospital/Unit
Pediatric Hospital
Outpatient
In-Patient Psych
School
Older Adult Day
Program
Outpatient/hand
private practice
Adult Day Program
for DD
Home Health
Pediatric Outpatient
Clinic
From: http://www.aota.org/Educate/Accredit/Forms/GeneralUse/FormA.aspx
* Some facilities offer multiple practice settings. For example, large health systems may offer inpatient acute, in-patient rehab, and general rehab outpatient.
Practice Setting Definitions
In-Patient Acute: care provided to patients who have a sudden and short-term need for services and
are typically seen in the hospital, many services offered; fast-paced, average length of stay 3-5 days
Fieldwork Student Manual
updated 1/2014
35
In-Patient Rehab: highly structured schedule, intense interdisciplinary intervention focus, average
length of stay 2 weeks
Skilled Nursing Facility (SNF)/Sub-Acute/Acute Long-Term Care
Skilled Nursing Facility (SNF): provides less intensive level of care for individuals who need
acute or chronic nursing care on a regular basis but do not need to be hospitalized; care is
administered by nursing professionals under the direction of a physician; available services
include assistance with Activities of Daily Living (ADLs), rehabilitation, meals/snacks,
social/recreational activities, housekeeping, transportation, etc.; may also provide specialized
services for those with Alzheimer’s or other related memory disorders
Sub-Acute: less intensive level of care; typically in a hospital; complex medical situations
requiring longer period of rehabilitation and recover usually from 1-4 weeks (e.g., persons with
strokes, hip fractures, cancer, cardiac condition, etc.)
Acute Long-Term Care: patients are medically stable, but are fragile and too ill to be
discharged to a nursing facility, an inpatient rehabilitation hospital or to their homes; often
require extended medical and nursing care
General Rehab Outpatient: serves clients with disabling conditions and may focus on medical
issues; oftentimes, clients have been recently discharged from a hospital setting and are still in need
of therapy services (but which can be provided at a lower level of care); treatment frequency varies
from 5 days per week to once every other week
Outpatient Hands: In addition to the features of General Rehab Outpatient, this setting focuses
solely on treating persons with conditions of the upper extremity and typically includes therapeutic
exercise, splinting, and physical agent modalities as primary interventions
Pediatric Hospital/Unit: provides care to children who have a sudden and short-term need for
services; many services offered; fast-paced
Pediatric Hospital Outpatient; serves children with disabling conditions and may focus on medical
issues; oftentimes, clients have been recently discharged from a hospital setting and are still in need
of therapy services (but which can be provided at a lower level of care)
In-Patient Psych: offers traditional psychiatric occupational therapy programs where clinician plans
activities (e.g., crafts, recreation, outings) for the purposes of skill development, self-awareness,
leisure exploration, and social participation
Pediatric Community: pediatric programs that are not hospital-based or outpatient clinical sites; may
vary according to community
Behavioral Health Community: vary in organization and structure, may offer medication clinics and
counseling, crisis units, or day treatment programs, clinicians work with a client or group to develop
life skills, to encourage social participation, to explore leisure opportunities, and to develop abilities to
engage in areas of performance
Older Adult Community Living
Assisted Living: a combination of housing, personalized supportive services and health care
designed to meet the needs – both scheduled and unscheduled – of those who need help with
Fieldwork Student Manual
updated 1/2014
36
activities of daily living; facilities vary in location and structure; available services include meals,
housekeeping, transportation, assistance with Activities of Daily Living (ADLs), wellness programs,
pastoral care services, 24-hour staff, etc.; may also provide specialized services for those with
Alzheimer’s or other related memory disorders
Continuing Care Retirement Communities (CCRC): offers several levels of assistance, including
independent living, assisted living, and nursing home care; is different from other housing and care
facilities for seniors because it provides a written agreement or long-term contract between the
resident (frequently lasting a lifetime) and the community which offers a continuum of housing,
services, and care, commonly on one campus or site
Older Adult Day Program: serves older adults (e.g. adults with dementia) who need daytime
supervision or are able to live in the community but who require some assistance, clinicians develop
and provide structured programs of activities for clients
Outpatient/hand private practice: same as General Rehab Outpatient or Outpatient Hands, but
privately owned
Adult Day Program for DD: serves adults with development disabilities who need daytime
supervision or are able to live in the community but who require some assistance, clinicians develop
and provide structured programs of activities for clients
Home Health: therapy provided in the client’s natural home environment (e.g. house, assisted living
facility, etc.); clinicians travel to client’s location; providers may also work in the home of persons who
receive hospice care
Pediatric Outpatient Clinic: same as Pediatric Hospital Outpatient, but not located in a hospital
Early Intervention: services typically provided to children from birth to 3 years of age who have
disabilities or are at risk; goal is to enhance development, minimize the potential for developmental
delay, and help families to meet the special needs of their infants and toddlers
School: services provided to children in the school system that enable them to engage in education
and be successful in the classroom; clinicians may work in standard schools or specialized schools
(e.g., for children with autism, visual impairment, hearing impairment, and cerebral palsy)
Nontraditional: may include correctional facilities, industrial settings, hospice, health maintenance
organizations, community transition programs, therapeutic riding programs, aqua therapy, senior
citizen centers, programs for migrant workers, homeless shelters, programs for victims of disasters,
etc.
Sources:
American Occupational Therapy Association. (2009). Occupational therapy in early intervention:
Helping children succeed. Retrieved November 19, 2009, from
http://www.aota.org/Consumers/WhatisOT/CY/Articles/40021.aspx
Hussey, S., Sabonis-Chafee, B., & O’Brien, J. (2007). Introduction to occupational therapy. St. Louis:
Mosby.
Step 3. Clinical Plan of Study Questionnaire
1. What drew you to occupational therapy?
Fieldwork Student Manual
updated 1/2014
37
2. Do you have any ideas of what or where you want your first job to be?
3. What past work or volunteer experiences in healthcare/childcare/senior care have you had?
4. What kind of job or practice setting would you find most rewarding? Least rewarding?
5. Is there a certain population (e.g., pediatrics, adults, elders) you desire to work with?
6. What practice setting(s) do you desire to learn more about?
Additional Thoughts/Comments/Questions:
Step 4. Clinical Plan of Study (CPOS)
OT1 Year
Spring
Summer
Practice Setting
Options
OTD 318
Level IA:
Mental Health
(throughout
semester)
OTD 390
Level IB:
Physical
Rehabilitation
(1 week)
OT2 Year
Fall
Mental Health
Local/Nonlocal (city/state)
(if known)
*Site name
(optional)
Clinical sites will be determined
and assigned by IOR of OTD 318
during Spring semester.
Inpatient Rehab
Inpatient Acute
SNF
General Outpatient
Outpatient Hands
Practice Setting
Local/Nonlocal (city/state)
(if known)
*Site name
(optional)
OTD 490
Level IC:
Fieldwork Student Manual
updated 1/2014
38
Pediatric or
Selected
Practice
Settings
(1 week)
Spring
Summer
OTD 491
Level ID:
Pediatric or
Selected
Practice
Settings
(1 week)
Spring
Pediatric
Setting of Interest
OTD 481
Level IIA:
(12 weeks)
OT3 Year
Fall
Pediatric
Setting of Interest
Practice Setting
Local/Nonlocal (city/state)
(if known)
*Site name
(optional)
OTD 571
Level IIB:
(12 weeks)
OTD 600
Professional
Rotation:
(16 weeks)
* Site names must come from Clinical Education database which can be found on the Clinical Education Database
SharePoint site. However, OTD 318 will be based on IOR selection & OTD 600 can be sites beyond the database.
Step 5. Remember to schedule a 1:1 meeting with your assigned ACEC to review your CPOS!
This form should be completed and submitted to the drop box PRIOR to your meeting. After
your meeting, submit your final (i.e. any discussed changes are incorporated) CPOS signed by
you and your ACEC by the due date
Student Signature:
Date:
ACEC Signature:
Date:
Fieldwork Student Manual
updated 1/2014
39
APPENDIX B
PERSONAL DATA SHEET
Fieldwork Student Manual
updated 1/2014
40
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)
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)
41
Electives - Fall
Spanish for Health Professionals (2)
CHIP (1-3)
Electives - Spring
Spanish for Health Professionals (2)
Institute for Latin American Concern Program
(3)
Clarion Case Competition (1)
Spirituality in OT Practice
Summary
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.
42
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
43
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.
44
APPENDIX C
SAMPLE
LEVEL I
PREFERENCE SHEET
Dates for Level I B-D will vary on form each semester.
Completed electronically on Clinical Education SharePoint Site
45
Fieldwork Preference Worksheet- Level IB
Your Level IB Fieldwork experience will take place during one week of the summer semester. While
completing this worksheet, please refer to your Clinical Plan of Study (CPOS) to guide your
preferences. Please circle your area(s) of interest for Level IB from the list below and cross out the
area in which you completed your Level IA fieldwork:
Hospital-based
Community-based
School-based
Other
In-Patient Acute
Pediatric Community
Early Intervention
Nontraditional
In-Patient Rehab
Behavioral Health
Community
Older Adult Community
Living
Older Adult Day
Program
Outpatient/hand private
practice
Adult Day Program for
DD
Home Health
School
SNF/Sub-Acute/Acute
Long-Term Care
General Rehab
Outpatient
Outpatient Hands
Pediatric Hospital/Unit
Pediatric Hospital
Outpatient
In-Patient Psych
Pediatric Outpatient
Clinic
Level IA Fieldwork completed at: ________________________________________
Please check one of the lines below:
_____ I would like to complete my fieldwork in the Omaha/Lincoln/Council Bluffs area and I have no preference for a
specific site.
_____ I would like to complete my fieldwork in the Anchorage/Mat-Su Valley area and I have no preference for a specific
site. Alaska sites preference in-state students.
_____ I am interested in completing my fieldwork at one of the following specific sites listed below. I
understand I need to choose my clinical site using the Fieldwork Site Listing posted on the course
website and from the site files in the Clinical Education Office. I understand I am not guaranteed my
site choices. If the sites listed below are unavailable, I understand I will be placed locally based on
my area(s) of interest identified above and on my CPOS. Here are my top 3 choices, listed by site
and city/state:
1. ___________________________________________________________
2. ___________________________________________________________
3. ___________________________________________________________
We will do our best to accommodate your interests and choices. You will be notified of your Level IB
Fieldwork placement via email before the end of the semester. Please wait to complete your
Personal Data Sheet until you know your site in order to tailor your responses to your site.
46
APPENDIX D
LEVEL IB-ID
STUDENT PERFORMANCE EVALUATION
Please return this form by hand, by mail, or fax to:
Academic Clinical Education Coordinator
Department of Occupational Therapy
School of Pharmacy and Health Professions
Creighton University
2500 California Plaza
Omaha, NE 68178
402-280-5692
47
Heartland Occupational Therapy Fieldwork Alliance
Level I Fieldwork Student Evaluation
Creighton University Occupational Therapy Department
Student Name: _________________________________________________
Course Number:
_______________
Facility Name: _________________________________________________
Dates of Fieldwork: _______________
School Name: Creighton University
Type of Setting: _________________________
Please indicate the student's performance on each item using the rating scale below.
The following definitions are provided for consistency and clarity. Remember to consider students will need clinical supervision
and guidance during this experience. The focus of these experiences is not intended to be independent performance.
Needs Improvement (N):
Performance is inconsistent or requires constant supervision and cueing/assistance from clinical instructor to perform tasks safely
and effectively. Performance is weak in many of the required tasks or activities and may occasionally be unacceptable. This student
might show minimal interest in the activities/tasks. Opportunities for improvement exist, but further training/experience is indicated.
Meets Expectations (M):
Carries out required tasks and activities in a safe and effective manner. This student demonstrates good solid performance in
required activities and shows initiative/enthusiasm. This rating would ideally be used more than all others.
Exceeds Expectations (E):
Frequently demonstrates clinical performance that surpasses requirements. At times, performance is exceptional.
This student shows initiative above what is expected.
Not Applicable/No Opportunity (NA):
This is to be used when an item to be scored either was not observed by the supervisor or there was no opportunity
for the activity to occur in this setting.
RATING ____
1. TIME MANAGEMENT SKILLS
Is prompt, responsible, and flexible.
Comments: _______________________________________________________________________________________
____________________________________________________________________________________________________
RATING ____
2. ORGANIZATION
Sets priorities, is dependable, organized, and follows through with responsibilities.
Plans adequately to complete program assignments.
Comments: ________________________________________________________________________________________
___________________________________________________________________________________________________
RATING ____
3. WRITTEN COMMUNICATION
Correct grammar, spelling and legibility are noted. Information contained in the written work
matches the consumer activity in which the student participated or observed.
Comments: ________________________________________________________________________________________
___________________________________________________________________________________________________
RATING ____
4. CLINICAL REASONING/PROBLEM SOLVING
Self reflective, willing to ask questions, able to analyze, synthesize and interpret information;
understands the OT process.
Comments: ________________________________________________________________________________________
___________________________________________________________________________________________________
5. USE OF PROFESSIONAL ETHICS
RATING ____
A. Respects confidentiality and consumer's rights
RATING ____
B. Uses precautions and effective safety techniques at all times
RATING ____
C. Complies with facility's policies and procedures
Comments: ________________________________________________________________________________________
___________________________________________________________________________________________________
48
RATING ____
6. OBSERVATION SKILLS
Observes relevant behaviors for performance areas and performance components
and verbalizes perceptions and observations.
Comments: _____________________________________________________________________________________
________________________________________________________________________________________________
RATING____
7. PARTICIPATION IN THE SUPERVISORY PROCESS
Gives, receives and responds to feedback; seeks guidance when necessary;
follows proper lines of command.
Comments: _____________________________________________________________________________________
________________________________________________________________________________________________
RATING ____
8. VERBAL COMMUNICATION AND INTERPERSONAL SKILLS WITH CONSUMERS/STAFF/CAREGIVERS
Interacts appropriately with individuals (e.g.- eye contact, empathy, active listening, respectfulness,
use of authority, etc; degree/quality of verbal interactions; use of body language and non-verbal communication)
Comments: _____________________________________________________________________________________
________________________________________________________________________________________________
RATING ____
9. PATIENT RELATED ACTIVITIES
Develops therapeutic relationship with consumer taking into consideration contextual dimensions
(religion, ethnicity, culture, lifestyle); generates appropriate strategies to facilitate achievement
of consumer's goals and if feasible plans and assists with carrying out one or more
intervention/evaluation sessions.
Comments: _____________________________________________________________________________________
________________________________________________________________________________________________
10. PROFESSIONAL BEHAVIOR
RATING ____
A. Overall appearance and dress appropriate for the facility
RATING ____
B. Asks appropriate questions and shows initiative to seek and acquire information from a variety of resources
RATING ____
C. Shows the ability to take responsibility for own learning and demonstrates motivation
RATING ____
D. Sets appropriate limits in response to undesirable physical or social behaviors if applicable
RATING ____
E. Deals with personal emotions maturely
RATING ____
F. Demonstrates ability to work in collaboration with the consumer and/or family and a variety of service providers
Comments: _____________________________________________________________________________________
________________________________________________________________________________________________
RATING ____
11. OVERALL IMPRESSION OF STUDENT'S PERFORMANCE
(An ‘N’ rating indicates the need for the student to repeat the clinical experience.)
Comments: _____________________________________________________________________________________
________________________________________________________________________________________________
_________________________________ __________
Student Signature
Date
______________________________________
Signature of Rater and Title
__________
Date
49
APPENDIX E
SAMPLE
LEVEL IB-ID
STUDENT EVALUATION OF
FIELDWORK EXPERIENCE
50
Department of Occupational Therapy
2500 California Plaza, Omaha, NE 68178
Phone (402) 280-5929 Fax (402) 280-5692
Level IB Fieldwork Experience
Student Evaluation
Student Name:
Site Name:
Site Address:
Site Phone:
Fieldwork Educator:
Fieldwork Dates:
1. Please summarize your experience. (Include how you spent your time during the week, what
activities/aspects of the therapy process [evaluation or intervention] you were able to
participate in, other professionals observed, meetings or in-services attended, etc.)
2. Did you complete the following fieldwork learning experiences assigned by Creighton
University: treatment session/fieldwork educator observations, SOAP note (or other format)
with feedback from fieldwork educator, & self-reflection? ____ Yes ___ No
If no, please provide a rationale for why learning experiences were not completed:
3. What were the most beneficial assignments or activities (either from Creighton or your site)
during this experience? Please describe.
4. How was your professional development enhanced through this experience? How do you
see your top five signature themes from your StrengthsFinder Profile incorporating into your
professional identity?
51
5. What material from your didactic class work was clarified through this experience?
6. What new concepts about occupational therapy, or the clients you encountered, did you
learn from this experience?
7. What would you recommend another student do as preparation for this site?
8. Identify your strengths and areas for growth during this fieldwork experience.
9. Identify the site/fieldwork educators’ strengths and any suggestions for improvement.
10. Describe your overall impressions of this site.
Date: ______________
Fieldwork Educator(s)’ signature(s):_______________________
Date: ______________
Student's signature: _______________________________
Please review this form with your Fieldwork Educator(s) before the last day of your scheduled fieldwork
experience.
52
Level I Fieldwork Housing Options Form
Please complete the following form if your site is more than 75 miles outside of Omaha or
Anchorage to inform other students about housing options during the Level I Fieldwork
experience.
Name of Student: ___________________________
E-mail Address: __________________________
Can a student contact you for information?
□ YES
Site Name:
_______________________
Dates of Fieldwork:________________________
□ NO
1. Living accommodations (include type, cost, location, condition):
2. Public transportation in the area:
3. Other available housing options/information:
53
APPENDIX F
LEVEL II
FIELDWORK PREFERENCE FORM
54
Level II Fieldwork Site Preference List
For Summer 2015
Due:
September 12 - If you miss this deadline, you will be randomly assigned AFTER the placement
process is completed.
Where:
on Clinical Education SharePoint database http://otclined.creighton.edu
What:
Please list sites and city/state in order of preference with #1 as your FIRST choice and #5 as your
LAST choice. If you select a site that has multiple locations, e.g. Rehab Visions, or multiple
practice settings within one site, e.g. inpatient acute, outpatient, you must indicate your specific
interest on this form. Thank you!
Printed Name:
1.
Level IIA OR Level IIB
Site:
City/State:
2.
Site:
City/State:
3.
Site:
City/State:
4.
Site:
City/State:
5.
Site:
City/State:
6.
Site:_____________________________________________________________
City/State: _________________________________________________
7.
Site:
City/State:
8.
Site:
City/State:
9.
Site:
City/State:
10.Site:
City/State:
55
APPENDIX G
LEVEL II
ASSIGNMENT AGREEMENT
56
LEVEL II FIELDWORK ASSIGNMENT AGREEMENT FORM
(to be completed electronically in SharePoint site)
I have worked collaboratively with the Academic Clinical Education Coordinator in
selecting the following site for Level II fieldwork.
Fieldwork Practice Setting: ______________________________
Facility Name: _________________________________________________________
Location:______________________________________________________________
Dates:________________________________________________________________
I agree that unless the facility cancels this placement, no changes will
be made to the fieldwork assignment.
_____________________________________________________________________
Student Signature
Date
57
APPENDIX H
LEVEL II
STUDENT FIELDWORK
CONFIRMATION FORM
58
Department of Occupational Therapy
2500 California Plaza, Omaha, NE 68178
Phone (402) 280-5929 Fax (402) 280-5692
Student Fieldwork
Confirmation Form
FROM:
TO:
Academic Clinical Education Coordinator
Department of Occupational Therapy
School of Pharmacy and Health Professions
Creighton University
2500 California Plaza
Omaha, Nebraska 68178
402.280.5631
Name of Student:
Type of Fieldwork:
Dates:
I accept responsibility of the above student for fieldwork education during the dates
noted above.
I verify that I have reviewed the current existing affiliation agreement, and the student(s)
shall be supervised by an occupational therapist that meets state regulations and has a
minimum of one year experience.
Director of Occupational Therapy or Clinical Instructor
Date Signed
Comments:
Please return to the above address.
Date returned _________
59
APPENDIX I
LEVEL II
STUDENT EVALUATION
OF FIELDWORK EXPERIENCE
60
STUDENT EVALUATION OF THE FIELDWORK EXPERIENCE (SEFWE)
This form is accessible via the Clinical Education SharePoint site and should be completed
electronically.
Purpose: This evaluation serves as a tool for fieldwork sites, academic programs, and students. The
main objectives of this evaluation are to:
 Enable the Level II fieldwork student who is completing a placement at the site to evaluate
and provide feedback to the supervisor and fieldwork setting;
 Enable academic programs, fieldwork sites, and fieldwork educators to benefit from student
feedback in order to develop and refine their Level II fieldwork programs;
 Ensure that all aspects of the fieldwork program reflect the sequence, depth, focus, and
scope of content of the curriculum design;
 Provide objective information to students who are selecting sites for future Level II fieldwork;
and
 Provide a means of evaluation to ensure that fieldwork is performed in settings that provide
educational experiences applicable to the academic program.
This form is designed to offer each program the opportunity to gather meaningful and useful information.
Sections outlined with thick black double borders are designed to be customized by your program as
needed. Pages involving evaluation of individual fieldwork educators have been positioned at the end of
the form to allow academic programs to easily remove these pages before making them available for
student review, if they choose to do so.
61
STUDENT EVALUATION OF THE FIELDWORK EXPERIENCE (SEFWE)
Instructions to the Student:
Complete this STUDENT EVALUATION OF THE FIELDWORK EXPERIENCE (SEFWE) form before your
final meeting with your fieldwork supervisor(s). It is imperative that you review the form with your
supervisor and that both parties sign on page 1. Copy the form so that a copy remains at the site and the
original is forwarded to your Academic Fieldwork Coordinator at your educational program. This
information may be reviewed by future students as well. The evaluation of the student (FWPE) should be
reviewed first, followed by the student’s evaluation of the fieldwork experience (SEFWE), allowing the
student to be honest and constructive.
Fieldwork Site _________________________________________________________
Practice Area(s) ________________________________________________________
Address ______________________________________________________________
Placement Dates: from _________________________ to _______________________
Order of Level II Placement:
[ ] Level II A
[ ] Level II B
Living Accommodations: (include type, cost, location, condition)
Public transportation in the area:
Please write your e-mail address here if you don’t mind future students contacting you to ask you about your
experience at this site: ______________________________________
We have mutually shared and clarified this Student Evaluation of the Fieldwork Experience report.
_______________________________________
Student's Signature / Date
_______________________________________
Student's Name (Please Print)
________________________________________
FW Educator's Signature / Date
________________________________________
FW Educator’s Name and Credentials (Please Print)
FW Educator’s years of experience ____________
62
ORIENTATION
Indicate your view of the orientation by checking "Satisfactory" (S) or "Needs Improvement” (I) regarding
the three factors of adequacy, organization, and timeliness.
TOPIC
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Adequate
S
I
Organized
S
I
Timely
S
I
NA
Site-specific fieldwork objectives
Student supervision process
Requirements/assignments for students
Student schedule (daily/weekly/monthly)
Staff introductions
Overview of physical facilities
Agency/Department mission
Overview of organizational structure
Services provided by the agency
Agency/Department policies and procedures
Role of other team members
Documentation procedures
Safety and emergency procedures
Confidentiality/HIPAA
OSHA—Standard precautions
Community resources for service recipients
Department model of practice
Role of occupational therapy services
Methods for evaluating OT services
Other
Comments or suggestions regarding your orientation to this fieldwork placement:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
CASELOAD
List approximate number of each age
category in your caseload.
Age
Number
List approximate number of each primary
condition/problem/diagnosis in your caseload
Condition/Problem
Number
0–3 years old
3–5 years old
6–12 years old
13–21 years old
22–65 years old
> 65 years old
63
OCCUPATIONAL THERAPY PROCESS
Indicate the approximate number of screenings/evaluations you did; also indicate their value to your
learning experience by circling the appropriate number with #1 being least valuable and #5 being the
most valuable.
REQUIRED
Yes
No
HOW
MANY
1. Client/patient screening
EDUCATIONAL
VALUE
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
3. Written treatment/care plans
1
2
3
4
5
4. Discharge summary
1
2
3
4
5
2. Client/patient evaluations
(Use specific names of evaluations)
List major therapeutic interventions frequently used and indicate whether it was provided in group,
individually, co-treatment, or consultation. List other professionals involved.
Therapeutic Interventions
Individual
Group
Co-Tx
Consultation
Occupation-based activity, i.e., play, shopping, ADL, IADL,
work, school activities, etc. (within client’s own context with
his or her goals)
1.
2.
3.
4.
Purposeful activity (therapeutic context leading to
occupation)
1.
2.
3.
4.
64
5.
Preparatory methods, i.e., sensory, PAMs, splinting,
exercise, etc. (preparation for occupation-based activity)
1.
2.
3.
4.
THEORY—FRAMES OF REFERENCE—MODELS OF PRACTICE
Indicate frequency of theory/frames of reference used
Never
Rarely
Occasionally
Frequently
Model of Human Occupation
Occupational Adaptation
Ecology of Human Performance
Person–Environment–Occupation Model
Biomechanical Frame of Reference
Rehabilitation Frame of Reference
Neurodevelopmental Theory
Sensory Integration
Behaviorism
Cognitive Theory
Cognitive Disability Frame of Reference
Motor Learning Frame of Reference
Other (list)
FIELDWORK ASSIGNMENTS
List the types of assignments required of you at this placement (check all that apply), and
indicate their educational value (1 = not valuable ------- 5 = very valuable)
Blueline Discussion
1
2
3
4
5 N/A
Curriculum Design Review Form
1
2
3
4
5 N/A
Psychosocial Application to Practice Paper
1
2
3
4
5 N/A
Other (list):
1
2
3
4
5 N/A
Other (list):
1
2
3
4
5 N/A
Other (list):
1
2
3
4
5 N/A
Other (list):
1
2
3
4
5
N/A
65
1 = Rarely
2 = Occasionally
3 = Frequently
4 = Consistently
ASPECTS OF THE ENVIRONMENT
1
2
Slow
Med
3
4
Staff and administration demonstrated cultural sensitivity
The Practice Framework was integrated into practice
Student work area/supplies/equipment were adequate
Opportunities to collaborate with and/or supervise OTs, OTAs, and/or aides
Opportunities to network with other professionals
Opportunities to interact with other OT students
Opportunities to interact with students from other disciplines
Staff used a team approach to care
Opportunities to observe role modeling of therapeutic relationships
Opportunities to expand knowledge of community resources
Opportunities to participate in research
Additional educational opportunities (specify):
How would you describe the pace of this setting? (circle one)
Types of documentation used in this setting:
Ending student caseload expectation:
_____ # of clients per week or day
Ending student productivity expectation: _____ % per day (direct care)
Fast
SUPERVISION
What was the primary model of supervision used? (check one)
one supervisor : one student
one supervisor : group of students
two supervisors : one student
one supervisor : two students
distant supervision (primarily off-site)
three or more supervisors : one student (count person as supervisor if supervision occurred at least
weekly)
List fieldwork educators who participated in your learning experience.
Name
Credentials
Frequency
Individual
Group
1.
2.
3.
4.
5.
66
ACADEMIC PREPARATION
Rate the relevance and adequacy of your academic coursework relative to the needs of THIS fieldwork
placement, circling the appropriate number. (Note: may attach own course number)
OTD 302 Occupations and Occupational Therapy
OTD 306 Health Conditions
OTD 314 Occupation and Health: Population Perspectives
OTD 316 Professional Practice and Ethical Formation
OTD 341 Neuroanatomy
OTD 300 Research Proposal
OTD 317 Occupational Therapy in Mental Health
OTD 324 Applied Kinesiology
OTD 339/340 Clinical Anatomy and Lab
OTD 355 Physical Rehabilitation I: Evaluation
OTD 356 Physical Rehabilitation II: Neurorehabilitation
OTD 333 Upper Extremity Evaluation and Intervention I
OTD 400 Research Project Implementation I
OTD 403 Neuro-Occupation
OTD 423 Occupational Therapy with Older Adults
OTD 433 Upper Extremity Evaluation and Intervention II
OTD 435 Occupational Therapy with Children and Youth I
OTD 442 Critical Analysis of Occupational Therapy Practice
OTD 460 Clinical Education Seminar I
OTD 401 Research Project Implementation II
OTD 406 Management and Program Development
OTD 417 Disability and Health Care Policy
OTD 436 Occupational Therapy with Children and Youth II
OTD 457 Physical Rehabilitation III: Interventions and Outcomes
OTD 461 Clinical Education Seminar II
OTD 564 Professional Identity and Ethical Perspectives
Level IA, IB, IC, ID Fieldwork
OTD 481 Level IIA Fieldwork
Adequacy for Placement
Low
High
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Relevance for Placement
Low
High
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
What changes would you recommend in your academic program relative to the needs of THIS
Level II fieldwork experience?
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
67
SUMMARY
1 = Strongly disagree
2 = Disagree
3 = No Opinion
4 = Agree
5 = Strongly agree
1
2
3
4
5
Expectations of fieldwork experience were clearly defined by
site
Expectations of site were challenging but not overwhelming
Experiences supported student's professional development
Experiences matched student's expectations
What particular qualities or personal performance skills do you feel that a student should have to
function successfully on this fieldwork placement?
________________________________________________________
________________________________________________________
________________________________________________________
What advice do you have for future students who wish to prepare for this placement?

Study the following evaluations:
________________________________________________________
________________________________________________________
________________________________________________________

Study the following intervention methods:
________________________________________________________
________________________________________________________
________________________________________________________

Read up on the following in advance:
________________________________________________________
________________________________________________________
________________________________________________________
Overall, what changes would you recommend in this Level II fieldwork experience?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
68
Please feel free to add any further comments, descriptions, or information concerning your fieldwork at this
center.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
1 = Strongly Disagree
2 = Disagree
3 = No opinion
4 = Agree
5 = Strongly agree
Indicate the number that seems descriptive of each fieldwork educator. Please
make a copy of this page for each individual.
FIELDWORK EDUCATOR NAME:__________________________________
FIELDWORK EDUCATOR YEARS OF EXPERIENCE: __________
1
2
3
4
5
Provided ongoing positive feedback in a timely manner
Provided ongoing constructive feedback in a timely manner
Reviewed written work in a timely manner
Made specific suggestions to student to improve performance
Provided clear performance expectations
Sequenced learning experiences to grade progression
Used a variety of instructional strategies
Taught knowledge and skills to facilitate learning and challenge student
Identified resources to promote student development
Presented clear explanations
Facilitated student’s clinical reasoning
Used a variety of supervisory approaches to facilitate student performance
Elicited and responded to student feedback and concerns
Adjusted responsibilities to facilitate student's growth
Supervision changed as fieldwork progressed
Provided a positive role model of professional behavior in practice
Modeled and encouraged occupation-based practice
Modeled and encouraged client-centered practice
Modeled and encouraged evidence-based practice
Frequency of meetings/types of meetings with supervisor (value/frequency):
General comments on supervision:
AOTA SEFWE Task Force, June 2006; updated by CU January 2014
69
APPENDIX J
LEVEL II
EVALUATION OF STUDENT
FIELDWORK EXPERIENCE
AOTA – FWPE
(Fieldwork Performance Evaluation Form)
The FWPE is filled out electronically on the
Clinical Education Database
Also located at:
http://www.aota.org/Educate/EdRes/Fieldwork.aspx
70
71
72
73
74
75
76
77
78
APPENDIX K
Fieldwork Experience Assessment Tool (FEAT)
79
FIELDWORK EXPERIENCE ASSESSMENT TOOL (FEAT)
Student’s name:
Supervisor(s) names:
Facility name:
Fieldwork experience type (setting, population,
level):
Date:
Week #:
Context:
The Fieldwork Experience Assessment Tool (FEAT) is the result of an American
Occupational Therapy Foundation qualitative study completed by six occupational therapy
programs across the United States and Puerto Rico. Data were collected from fieldwork
students and clinical instructors. In their interviews, students and clinical instructors
described fieldwork education in terms of a dynamic triad of interaction among the
environment, the clinical instructor, and the student. Interviewees indicated that a positive
educational experience occurred when a balance existed among these three key
components.
Purpose:
The FEAT identifies essential characteristics for each of the three key components. By
providing a framework to explore the fieldwork experience, the FEAT can help students
and clinical instructors consider how to promote the best possible learning experience.
The purpose of the FEAT is to contribute to student and clinical instructor discussions, so
that reflection and problem solving can occur to enhance the fieldwork experience. The
tool is designed to both assess the balance of the three key components, and to facilitate
discussion about student and clinical instructor behaviors and attitudes, and
environmental resources and challenges. By mutually identifying issues present during
fieldwork, the clinical instructor and student can use the FEAT as a tool to promote
dialogue, and foster the identification of strategies to facilitate the just-right challenge. The
FEAT may be used early in fieldwork as a tool to promote dialogue, or at anytime
throughout fieldwork as the need for problem solving emerges.
Directions:
In the Assessment Section, the FEAT is organized according to the three key components:
environment, clinical instructor, and student. Under each component, essential
characteristics and examples are listed. These examples are not all inclusive, and new
descriptors may be added to individualize the tool for different settings. The clinical
instructor and student, either individually or together, should complete the FEAT by
describing each component using the continuum provided at the top of each section (limited
 just right challenge  excessive).
Following the assessment portion of the FEAT, questions are provided to guide student and
clinical instructor discussion and problem solving. Collaboratively reflect upon the student
and clinical instructor descriptions on the FEAT to identify commonalities and differences
between the two perspectives, and identify patterns across the key components. Based on
these discussions, develop strategies for a more balanced fieldwork experience. Consider
environmental experiences and resources; clinical instructor attitudes, behaviors and
professional attributes; and/or student attitudes and behaviors that could enhance the
80
experience. The examples listed within each section are intended to guide discussion
between the clinical instructor and student in an effort to create a successful fieldwork
experience. Additional elements may be identified and included according to the nature of
the setting or the fieldwork process.
A. Assessment Section
ENVIRONMENT
Descriptions (Limited   Just right challenge  
Excessive)
I. VARIETY OF EXPERIENCES
A. Patients/Clients/Diagnoses
- Different diagnoses
- Range of abilities for given diagnosis
(complexity, function-dysfunction)
- Diversity of clients, including socioeconomic
& lifestyle
B. Therapy approaches
- Engage in the entire therapy process
(evaluation, planning, intervention,
documentation)
- Learn about different roles of therapist (direct
service, consultation, education &
administration)
- Use variety of activities with clients
- Observe and use different frames of reference/
theoretical approaches -Use occupation vs.
exercise
C. Setting characteristics
- Pace (setting demands; caseload quantity)
- Delivery system
Descriptions (Limited   Just right challenge  
Excessive)
II. RESOURCES
A. OT Staff
- See others' strengths and styles
- Have multiple role models, resources and
support
B. Professional Staff
- Observe and hear a different perspective on
clients - See/experience co-treatments and
team work to get
whole person perspective
- Have others to share ideas and frustrations
C. OT Students
- Able to compare observations & experiences
- Exchange ideas
CLINICAL INSTRUCTOR
I. ATTITUDE
Descriptions (Limited   Just right challenge  
Excessive)
A. Likes Teaching/Supervising Students
- Devote time, invests in students
- Enjoy mental workout, student enthusiasm
81
B. Available/Accessible-Take time
C. Supportive
- Patient
- Positive and caring
- Encourages questions
- Encourages development of individual style
CLINICAL INSTRUCTOR (continued)
D. Open
- Accepting
- Alternative methods
- To student requests
- Communication
E. Mutual Respect
II. TEACHING STRATEGIES
Descriptions (Limited   Just right challenge  
Excessive)
A. Structure
- Organize information (set learning objectives,
regular meetings)
- Introduce treatment (dialogue, observation,
treatment, dialogue)
- Base structure on student need
- Identify strategies for adjusting to treatment
environment
B. Graded Learning
- Expose to practice (observe, model)
- Challenge student gradually (reduce direction,
probing questions, independence)
- Base approach on student learning style
- Individualize based on student’s needs
- Promote independence (trial & error)
C. Feedback/ Processing
- Timely, confirming
- Positive and constructive (balance)
- Guide thinking
- Promote clinical reasoning
D. Teaching
- Share resources and knowledge
E. Team Skills
- Include student as part of team
III. PROFESSIONAL ATTRIBUTES
Descriptions (Limited   Just right challenge  
Excessive)
82
A. Role Model
- Set good example
- Enthusiasm for OT
- Real person
- Lifelong learning
B. Teacher
- Able to share resources and knowledge
FIELDWORK STUDENT
I. ATTITUDE
Descriptions (Limited   Just right challenge  
Excessive)
A. Responsible for Learning
- Active learner (ask questions, consult)
- Prepare (review, read and research materials)
- Self-direct (show initiative, is assertive)
- Learns from mistakes (self-correct and grow)
B. Open/ Flexible
- Sensitive to diversity (non-judgmental)
- Responsive to client/consumer needs
- Flexible in thinking (make adjustments,
try alternate approaches)
C. Confident
- Comfort in knowledge and abilities
- Comfort with making and learning from
mistakes
(take risks, branch out)
- Comfort with independent practice
(take responsibility)
- Comfort in receiving feedback
D. Responsive to Supervision
- Receptive to feedback
(open-minded, accept criticism)
- Open communication (two-way)
II. LEARNING BEHAVIORS
Descriptions (Limited   Just right challenge  
Excessive)
A. Independent
- Have and use knowledge and skills
- Assume responsibility of OT
without needing direction
- Incorporate feedback into behavioral changes
- Use “down time” productively
- Become part of team
B. Reflection
- Self (processes feelings, actions and
feedback)
- With others (supervisor, peers others)
C. Active in Supervision
- Communicate needs to supervisor (seek
supervision
for guidance and processing; express needs)
- Ask questions
83
B. Discussion Section: Questions to Facilitate Dialogue and Problem Solving
1. A positive fieldwork experience includes a balance between the environment, clinical
instructor and student components. Collaboratively reflect upon the descriptions outlined by
the student and clinical instructor and identify perceptions below.
Common perspectives between student
and clinical instructor
Environment
Different perspectives between student
and clinical instructor
Clinical instructor
Student
2. What patterns are emerging across the three key components?
3. What strategies or changes can be implemented to promote a successful fieldwork experience?
Describe below:
Components of a
Successful Fieldwork
Environment
Experiences
Environment, Clinical instructor and/or Student Strategies and Changes
to Promote Successful Fieldwork Experience at this Setting
Resources
Clinical instructor
Attitudes
Behaviors
Professional attributes
Student
Attitudes
Behaviors
This Fieldwork Experience Assessment Tool (FEAT) was developed by The Fieldwork Research Team:
Karen Atler, Karmen Brown, Lou Ann Griswold, Wendy Krupnick, Luz Muniz de Melendez and Patricia Stutz-Tanenbaum
Project funded by The American Occupational Therapy Foundation and AOTA Education Special Interest Section
[April 1998; revised August 2001] FEAT 13.doc
84
APPENDIX L
FIELDWORK CHECKLIST
85
CHECKLIST FOR ALL FIELDWORK EXPERIENCES
Before starting FW assignment




Provide Student Health with all of your completed health requirements. It is strongly
recommended that students keep their own record of the following documents:
 Immunizations, including results of annual TB test
 CPR certification
 Blood-borne Pathogens Training Quiz
 HIPAA Training Quiz
Provide Assistant Clinical Education Coordinator with your current Personal Data Sheet.
This should include your contact information (address and telephone number) for the
summer.
Review FW Manual and course syllabi that corresponds to fieldwork experience, especially
confidentiality policy.
Contact assigned FWEd at least one month prior to start date for Level I Fieldwork
and four to six weeks for Level II Fieldwork regarding health requirements, drug
screening, criminal background check, times/locations to report, dress code, parking, job
requirements, etc.
Upon arrival and during FW experience




You must check your Creighton University email on a weekly basis.
Confirm that your site has received the packet of information regarding your placement.
Complete assignments outlined in corresponding fieldwork syllabi (Level I and Level II)
Complete site specific assignments (Level I and Level II)
Upon successful completion of FW experience




Complete evaluations (Fieldwork Educator and Student).
both evaluations.
Both signatures required on
Assure evaluations are completed and submitted upon completion of FW experience.
It is recommended that both the student and fieldwork educator make a copy of the
evaluations to keep for their records.
Letter of appreciation/thank you to your fieldwork educator for hosting your FW experience.
(see Appendix N for a sample)
86
APPENDIX M
LEVEL II
SUGGESTED FORMAT FOR
WRITING TO YOUR FIELDWORK SITE
87
SUGGESTED FORMAT
FOR WRITING TO YOUR LEVEL II FIELDWORK SITE
The purpose of this letter is to introduce yourself and make contact with your fieldwork
educator. This is your professional contact with your fieldwork educator and the letter
should be typed and professional in appearance. Use the name and address as it
appears on the Fieldwork Roster. Give a copy of the letter to the instructor of record
and maintain a copy of the letter and keep for future reference if needed. Mail it no later
than four to six week prior to start date.
You should include:

Beginning and ending dates

Name and appropriate contact information for the fieldwork site

Confirm working hours

Confirm dress code

Ask for assistance locating housing (if needed)

Confirm housing and/or stipend if provided

Your address and phone number where you can be reached immediately preceding your
start date
Some of this information may be in the student fieldwork file. It would be a good idea to
review the file for information such as maps, dress code, and hours; then, in your letter
state something to this effect: “It is my understanding that fieldwork hours are from 8:00
to 4:30 and that students are to wear lab coats with a patch and name tag.”
You could begin your letter something like this: “I am scheduled for my Level II Mental
Health fieldwork at (name of site) and am writing to introduce myself (or to confirm the
details of my placement).” You might end the letter by saying, “I am looking forward to
meeting you and to my fieldwork experience at your (center, site, hospital, clinic).”
88
APPENDIX N
Sample Thank You Letter
Sample Thank You Letter to Fieldwork Educator After Fieldwork Experience
Date
Dear (Name of Fieldwork Educator),
Thank you so much for giving me the opportunity to complete the fieldwork component
of my occupational therapy education under your guidance and direction. During my
fieldwork, I was able to grow and develop as a student therapist, giving me the chance
to apply my skills learned in the classroom to the clinic. Your feedback and leadership
armed me with the skills I will need as I begin my professional career.
Give an example of how their leadership helped make you a better therapist.
Again, thank you for all your guidance and leadership as I grow as a professional.
Sincerely,
Signature
Name
89
APPENDIX O
LEVEL II
SITE RECOMMENDATION FORM
90
Creighton University Department of Occupational Therapy
Fieldwork site Recommendation Form
Your Name: ________________________________
Date: ______________
Facility Name: _____________________________________________________
Facility Address: ___________________________________________________
City: ____________________ State: __________ Zip: __________
Phone: (___)_________________
Name of Center Coordinator: _______________________________
Name of OT Contact: _____________________________________
Why would this site be an asset to the clinical education program as a whole?
How does this site meet the objectives of the OTD program?
What makes this site unique?
What specialty programs does this site offer?
How is this site different from others in a similar practice setting?
91
Rationale must be clear but concise and does not include “this is a really good site!”, or
“its where my aunt lives”.
Note: Incomplete forms or forms without adequate justification will be returned
to the student. Forms must be submitted in sufficient time to allow for
development of the site.
Received by: ________________________ Date: ________________________
Reviewed by Clinical Education Faculty on: ____________________________
.
The clinical education office has reviewed this form and has reached the following
consensus:
_____ A contract will not be pursued with this site. The rationale for
this decision is as follows:
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
_____ A contract will be pursued with this site per site development procedures.
You will be notified of the outcome.
Signed: ________________________________
Date: ________________
92
APPENDIX P
LIABILITY COVERAGE
93
CERTIFICATE OF INSURANCE
This is to certify that the Midwest Medical Insurance Company has issued to the insured the policy identified
herein by policy number, policy term and limits of liability, which affords PHYSICIANS AND SURGEONS
PROFESSIONAL LIABILITY INSURANCE. This certificate of insurance does not amend, extend or
otherwise alter the terms, conditions or limits of the insurance afforded by the policy.
INSURED’S NAME:
Creighton University
ADDRESS:
2500 California Plaza
Omaha, NE 68178
POLICY TYPE:
Claims Made
POLICY NUMBER:
IXC000009
POLICY LIMITS:
$1,000,000 each claim
$3,000,000 aggregate
SHARED EXCESS LIMIT:
$5,000,000
POLICY TERM:
07/01/2013 to 07/01/2014
RETROACTIVE DATE:
07/01/1986
CERTIFICATE HOLDER:
Any student of the named insured, but only for legal liability arising
out of the performance of, or failure to perform, duties while acting
within the scope of their duties as students.
Retroactive date is the date listed on the declarations page which is the first date that coverage applies
to any claim or suit covered under this policy.
Excess retroactive date is the first date that coverage applies to that portion of a claim or suit
exceeding one million dollars each claim or three million dollars aggregate.
If the insured type listed above is shown as clinic, hospital, or individual practitioner, employees of the
insured are included as additional insureds while acting within the scope of their employment duties for the
insured. This additional coverage excludes coverage for interns, externs, residents, dental, osteopathic or
medical doctors, podiatrists, nurse mid-wives, certified registered nurse anesthetists and heart/lung
perfusionists.
If this policy is cancelled by MMIC before the expiration date shown, MMIC will endeavor to mail advance
written notice to the certificate holding organization or hospital. Failure to mail such a notice will impose no
obligation or liability of any kind upon MMIC.
Policy Number: IXC000009
Issue Date: 2/9/2016
MIDWEST MEDICAL INSURANCE COMPANY
7650 EDINBOROUGH WAY, SUITE 400, MINNEAPOLIS, MN 55435-5978
PH.(952) 838-6700 OR 1-800-328-5532 FAX (952) 838-6808
COFI600 Manual
94
APPENDIX Q
INCIDENT REPORT FORM
95
Creighton University Incident Report Form (HR-24)
Risk Management Office
For Accident, Injury or Blood/Body Fluid Exposure Reporting
402.280.5833; 402.280.5719 (fax)
Report of Alleged Accident. This report must be filed with the Risk Management Office within 24 hours after the accident.
Do not make any statements and refer all questions to the Risk Management Office.
Please print or type all information. If additional space is needed, attach a separate sheet.
Injured:
Employee
Non-Employee (specify)
Name:
SS#:
Birth date:
Age:
Gender:
M
F Marital Status:
Home Address, City, State, & Zip:
Home Phone #: (
)
Employer (if other than Creighton):
Emergency Contact:
Accident/Injury Information:
Date of Accident:
Time of Accident:
Location (be specific):
Describe in detail what the injured was doing and how the accident happened:
Describe in detail nature and extent of injury/exposure (Specify location on the body -- also note right or left; If related
to sharp device, include: Type & brand of device; Type & amount of fluid or material, & severity of exposure -- As required by OSHA
Check type of injury:
Fracture
Laceration
Soreness/Pain
Eye Splash
Swelling
Bruise
Other (explain):
Needle Puncture Wound
Strain/ Sprain
For any illness felt to be job-related: Describe the illness to include the cause(s), type of illness, symptoms,
& how they have progressed including date(s) and current status:
Name(s) of Witness(es) & Phone #:
Did injured seek medical attention:
No
Yes --- Attach a copy of Physician’s Instructions/Restrictions
and provide Name & Address of doctor and/or hospital:
Employee Information Only: Dept. Phone #:
worked weekly:
Did injured lose work due to injury:
No
Time Work Day Began:
# of hours
Yes If yes, Date work loss began:
Date returned to
work::
Injured Party Signature:
Date:
96
Was a supervisor on duty at the time of accident/injury/exposure?
complete the following:
No
Yes -- If yes, supervisor must
Conditions or Contributing Factors to Accident/Injury/Exposure: (please check)
Lifting technique
Floor surface/ walkway
Tools or Equipment
None
Failure to wear protective equipment
Combative Patient
Distraction
Unsafe work area
Use of equipment
Other (please explain):
Corrective action taken:
Signature of Supervisor:
Date
97
APPENDIX R
VERIFICATION OF RECEIVING/REVIEWING
FIELDWORK STUDENT MANUAL
I, ______________________________________, acknowledge that I have
received and completely reviewed the professional rotation manual and take
personal responsibility for the information contained in it.
Student Signature:________________________________
Date:__________________________________________
98
Related documents
Download