AOTA FIELDWORK DATA FORM
Introduction:
The primary purpose of the Fieldwork Data Form is to summarize information regarding the program at a
fieldwork site. Occupational therapy (OT) and occupational therapy assistant (OTA) students will find valuable
information describing the characteristics of the fieldwork setting; the client population; commonly used
assessments; interventions; and expectations and opportunities for students. The Fieldwork Data Form has been
developed to reflect the Occupational Therapy Practice Framework: Domain and Process, 3rd Edition
(American Occupational Therapy Association [AOTA], 2014) terminology and best practice in occupational
therapy to promote quality fieldwork experiences. The data gathering processes used in completion of this form
entails a collaborative effort that facilitates communication between OT and OTA academic programs, students,
and fieldwork educators. This form may be completed by the combined efforts of the fieldwork educator, the
OT or OTA student assigned to the site for fieldwork, and/or the Academic Fieldwork Coordinator (AFWC)
from the program. Fieldwork sites are encouraged to update the form annually and provide a copy to the
educational program(s) where they have a current memorandum of understanding (MOU).
The secondary purpose of the Fieldwork Data Form is to document the connection between the curriculum
design of a given OT or OTA educational program with its fieldwork component. The AFWC will use the data
entered on the form to document fieldwork related Accreditation Council for Occupational Therapy (ACOTE)
Standards (ACOTE, 2012). The standards are outlined in Section C of the 2011 ACOTE standards and are
denoted on the form. Educational programs can revise the form to suit the needs of their respective fieldwork
programs.
The Fieldwork Data Form was developed through the joint efforts of the Commission on Education (COE) and
the Education Special Interest Section (EDSIS) Fieldwork Subsection with input from many dedicated AFWCs
and fieldwork educators.
AOTA FIELDWORK DATA FORM
Date: August 12, 2015
Name of Facility: Sinai Hospital
Address: Street: 2401 West Belvedere Ave
City: Baltimore
State: MD
FW I
Zip: 21215
FW II
Contact Person: Lauren Carls
Credentials: MS,
Credentials:
Contact Person: Same
OTR/L
Phone: 410-601-9632
Phone:
Email: lcarls@lifebridgehealth.org
Director: Ellen Zerbst
Phone: 410-601-5580
Fax: 410-601-6358
Website address: ezerbst@lifebridgehealth.org
Initiation Source:
 FW Office
Corporate Status:
 Nonprofit
OT Fieldwork Practice Settings:
RUBIN INSTITUTE FOR ADVANCED ORTHOPEDICS
AND INTERNATIONAL LIMB LENGTHENING CENTER
Hospital-based settings
Community-based settings







Inpatient Acute
Inpatient Rehab
SNF/Sub-Acute/Acute
Long-Term Care
General Rehab Outpatient
Outpatient Hands
Pediatric Hospital/Unit
Email:
Preferred Sequence of FW: ACOTE Standards B.10.6
 Any
School-based settings
Adult Day Program for Brain Injury
(RETURN program)
NA
Age
Groups:
 0–5
 6–12
 13–21
 22–64
 65+
Number of Staff:
2 OTRs
COTA
1 Aides
3 PT
0 Speech
0 Recreation Specialist
Student Prerequisites (check all that apply)ACOTE Standard C.1.2
CPR
First aid
Medicare/Medicaid fraud check
Infection control
Criminal background check
training
Child protection/abuse check
HIPAA training
Adult abuse check
Prof. liability ins.
Fingerprinting
Own transportation
 Interview
Health requirements:
HepB
MMR
Tetanus
 Chest x-ray (only if
Physical Check
Varicella
Influenza
appropriate)
Please list any other requirements:
up
Drug screening
TB/Mantoux
Please list how students should prepare for a FW II placement such as doing readings, learning specific evaluations and interventions used in
your setting: ACOTE Standards C.1.2, C.1.11

Therapist will be able to contact students prior to affiliation and provide them with certain topics/diagnoses (unit specific) to review prior to
start date
Student work schedule and outside
study expected:
Schedule hrs/week/day: 7-3:30pm
Other
Do students work weekends?  PRN
Meals no
Do students work evenings? NO
Stipend amount: no
Room provided no
Describe level of structure for
student?
 High (able to adjust this based on
Describe level of supervisory
support for student?
 High support (able to adjust this
students needs)
based on students needs)
Describe the FW environment/atmosphere for student learning:
We are a teaching hospital. We provide a fieldwork binder for the students with weekly guidelines/expectations for reference during the affiliation.
Student group meetings/in-services are conducted 1-2x/month which students are encouraged to attend. OT coordinator will meet specifically with
student on the first day, midterm, and during final week to assess progress and is also available to be contacted at any time with questions/concerns
during the entire fieldwork.
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Describe available public transportation: MTA
Types of OT interventions addressed in this setting (check all that apply):
Occupations: Client-directed occupations that match and support identified participation level goals (check all that apply):
ACOTE Standards C.1.8, C.1.11, C.1.12
Activities of Daily Living (ADL)
Bathing/showering
Toileting and toilet hygiene
Dressing
Feeding
Functional mobility
Personal device care
Personal hygiene and grooming
 Sexual activity
Rest and Sleep
 Rest
 Sleep preparation
 Sleep participation
Play
 Play exploration
 Play participation
Instrumental Activities of Daily Living (IADL)
Care of others/pets
Care of pets
Child rearing
Communication management
Driving and community mobility
Financial management
Health management and maintenance
Home establishment and management
Meal preparation and clean up
Religious / spiritual activities and expression
Safety and emergency maintenance
Shopping
Education
Formal education participation
Informal personal education needs or interests
exploration
Informal personal education participation
Leisure
Social Participation
 Leisure
 Leisure
exploration
participation
Work
Employment interests and pursuits
Employment seeking and acquisition
Job performance
Retirement preparation and adjustment
Volunteer exploration
Volunteer participation
Community
Family
Peer/friend
Activities: Designed and selected to
support the development of skills,
performance patterns, roles, habits,
and routines that enhance
occupational engagement
Practicing an activity
Simulation of activity
Role play
Examples:
Preparatory Methods and Tasks: Methods,
adaptations and techniques that prepare the
client for occupational performance
 Preparatory tasks
Exercises
Physical agent modalities
Splinting
Assistive technology
 Wheelchair mobility
Examples:
Education: describe
Method of Intervention
Outcomes of Intervention
Occupational performance improvement and/or
enhancement
Health and Wellness
Prevention
Quality of life
Role competence
Participation
Theory/Frames of Reference/Models of Practice
Biomechanical
Cognitive/Behavioral
Coping
Person-Environment-Occupation (PEO)
Psychosocial
 Rehabilitation frames of reference
Other (please list):
Direct Services/Caseload for entrylevel OT
 One-to-one
Small group(s)
Large group
Discharge/Outcomes of Clients (%
clients)

50% home

50% Rehab (SAR vs Aggressive
Rehab)
Training: describe
Advocacy: describe
Group Interventions: describe
OT Intervention Approaches
 Create, promote health/habits
 Establish, restore, remediate
 Maintain
 Modify, facilitate compensation, adaptation
 Prevent disability
Please list the most common screenings and evaluations used in your setting: MMT/ROM, Home safety evaluation
Identify safety precautions important at your FW site
Medications
Post-surgical (list procedures)
Contact guard for ambulation
 Fall risk
Swallowing/choking risks
Behavioral system/ privilege level
Sharps count
1 to 1 safety/suicide precautions
(locked areas, grounds)
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Performance skills, patterns, contexts and client factors addressed in this setting (check all that apply): ACOTE Standard C. 1.12
Performance Skills:
 Motor skills
 Process skills
 Social interaction skills
Performance Patterns:
Person:
 Habits
 Routines
 Rituals
Roles
Group or Population:
Habits
Routines
Rituals
Roles
Client Factors:
 Values
 Beliefs
 Spirituality
Mental functions (affective, cognitive, perceptual)
Sensory functions
 Neuromusculoskeletal and movement-related
functions
 Muscle functions
Movement functions
Cardiovascular, hematological, immunological, and
respiratory system functions
Voice and speech functions; digestive, metabolic, and
endocrine system functions;
 Skin and related-structure functions
Most common services priorities (check all that apply):
Direct service
Meetings (team, department, family)
Discharge planning
Client education
Evaluation
Intervention
Context(s):
Cultural
Personal
Temporal
Virtual
Environment:
Physical
Social
Consultation
In-service training
Billing
Documentation
Target caseload/productivity for fieldwork students:
Documentation: Frequency/Format (briefly describe) :
Productivity (%) per 40-hour work week: .55 BTU
Handwritten documentation: Outpatient
 Computerized medical records
Units
Caseload expectation at end of FW: 5-7 patients/day
Productivity (%) per 8-hour day: .55 BTU
Time frame requirements to complete documentation: Unit Specific but
approximately 15-20 minutes
Number groups per day expected at end of FW: None
Administrative/Management Duties or Responsibilities of the
OT/OTA Student:
Student Assignments. Students will be expected to successfully
complete:
 Schedule own clients
Supervision of others (Level I students, aides, OTA, volunteers)
Budgeting
Procuring supplies (shopping for cooking groups,
client/intervention-related items)
Participating in supply or environmental maintenance
Other:
 Research/EBP/Literature review
 In-service
 Case study
 In-service participation/grand rounds/PCC meeting
 Fieldwork project (describe) – discussion with CI and based on unit
specific needs
 Field visits/rotations to other areas of service
 Observation of other units/disciplines
Other assignments (please list):
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OPTIONAL DATA COLLECTION:
The question includes in this section may be used by academic programs to demonstrate compliance with the Accreditation Council
for Occupational Therapy Education (ACOTE) Standards documentation for fieldwork.
1.
Please identify any external review agencies that accredit / recognize this FW setting and year of accreditation/ recognition. Examples:
JCAHO, CARF, Department of Health, etc. .
Agency for External Review/ Year of most recent review: Joint Commission (2015); CARF (2013)
Summary of outcomes of OT Department review:
2.
Describe the fieldwork site agency stated mission or purpose: Attached
3.
OT Curriculum Design Integrated with Fieldwork Site (insert key OT academic curricular themes here) ACOTE Standards C.1.2, C.1.3,C.1.7, C.1.8, C.1.11,C.1.12
a. How are occupation-based needs evaluated and addressed in your OT program??
1. ADL assessment
2. Home safety evaluation
b.
Describe how you seek to include client-centered OT practice. How do clients participate in goal setting and intervention activities?
1.
2.
3.
Daily meetings with patient and family (will call family at home if needed) – goals established collaboratively
Monthly re-evaluations
Speak with interdisciplinary team members to plan for safest discharge disposition
c.
Describe how psychosocial factors influence engagement in occupational therapy services.
1. Patient may require increase encouragement to engage in therapy
2. May require more structured therapy times/treatments to meet patient expectations
d.
Describe how you address clients’ community-based needs in your setting.
1. Home safety evaluation
2. Discussion with family members to determine amount of assistance at home and work/home demands
4.
How do you incorporate evidence-based practice into interventions and decision making? Are FW students encouraged to provide evidence for
their practice? ACOTE Standards C.1.3, C.1.11
a. Students are always encouraged to provide evidence for practice/treatments
b. Journal clubs are attended by employees on a monthly basis and students are encouraged to attend and participate
5.
Please describe the FW Program and how students fit into the program. Describe the progression of student supervision from novice to entrylevel practitioner using direct supervision, co-treatment, and monitoring, as well as regular formal and informal supervisory meetings. Describe
the fieldwork objectives, weekly fieldwork expectations, and record keeping of supervisory sessions conducted with student. Please mail a copy
of the FW student objectives, weekly expectations for the Level II FW placement, dress code, and copy of an entry-level job description with
essential job functions to the AFWC. ACOTE Standards C.1.1, C.1.2, C.1.3, C.1.4, C.1.8, C.1.9

6.
Please describe the background of supervisors by attaching a list of practitioners who are FW educators including their academic program,
degree, years of experience since initial certification, and years of experience supervising students) ACOTE Standards C.1.9, C.1.14, C.1.17, C.1.19


7.
I have attached Sinai Hospital’s weekly fieldwork goals
All fieldwork educators are required to have worked minimum of 1 year at Sinai Hospital prior to accepting a student (level 1 or 2).
We are required yearly to accept OT/OTA students throughout our facility.
All field work educators are required to have >1, level 1 student prior to accepting a level 2 student
Describe the training provided for OT staff for effective supervision of students (check all that apply). ACOTE Standards C.1.9, C.1.15, C.1.16
a. CI Course provided at Sinai for new employees
b. CI’s are required to have Level 1 student prior to Level 2
c. Self assessment completed by all CI’s
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 Supervisory models: 1:1, student: supervisor model. Weekly student/fieldwork educator meetings are completed to assess progress which
are signed and filed. Students are required to have a midterm and exit interview meeting with the student coordinator for review of overall
progress.
 Training on use of FW assessment tools (such as the AOTA Fieldwork Performance Evaluation–FWPE, the Student Evaluation of
Fieldwork Experience–SEFWE, and the Fieldwork Experience Assessment Tool–FEAT): Training is provided in the CI Course at Sinai
Hospital.
 Clinical reasoning – Students are encouraged to use clinical reasoning and are expected to ask appropriate/relevant questions as needed
throughout the entire clinical process
 Reflective practice – Weekly meetings are performed to assess progress, recommendations and goals progress
Comments: We provide a fieldwork education course on a yearly basis for our new hires to prepare them for accepting a student
8.
Please describe the process for record keeping of supervisory sessions with a student, the student orientation process to the agency, OT services,
and the fieldwork experience. ACOTE Standards C.1.2, C.1.3, C.1.10
a. Unit specific binder - Initial orientation to unit with less caseload (review of all assessments and general process for treatments)
b. Weekly meetings CI and student – written
Records are filed and kept for 7 years following the student’s affiliation. The student will be oriented by the student coordinator on their first day of
affiliation.
Supervisory Patterns–Description (respond to all that apply)
 1:1 Supervision model:
Multiple students supervised by one supervisor:
Collaborative supervision model:
 Multiple supervisors share supervision of one student; number of supervisors per student: Multiple supervisors only if needed due to
scheduling/PTO days
Non-OT supervisors:
9.
Describe funding and reimbursement sources and their impact on student supervision.
STATUS/TRACKING INFORMATION SENT TO FACILITY:
Date:
ACOTE Standard C.1.6
Which documentation does the fieldwork site need?
 Fieldwork Agreement/Contract?
OR
Memorandum of Understanding (MOU)?
Which FW Agreement will be used?:  OT Academic Program Fieldwork Agreement
Fieldwork Site Agreement/ Contract
Title of Parent Corporation (if different from facility name): Lifebridge Health
Type of business organization (Corporation, partnership, sole proprietor, etc.): Hospital
State of incorporation: MD
Fieldwork site agreement negotiator: Lauren Carls
Phone: 410-601-9632
Email: lcarls@lifebridgehealth.org
Address (if different from facility):
Street:
City:
Name of student: Casey Smith
Potential start date for fieldwork: June 29 – September 18, 2015
State:
Zip:
Any notation or changes that you want to include in the initial contact letter:
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Information Status ACOTE Standards C.1.1, C.1.2, C.1.3, C.1.8,
 New general facility letter sent:
 Level I Information Packet sent:
 Level II Information Packet sent:
 Mail contract with intro letter (sent):
 Confirmation sent:
Model behavioral objectives:
 Week-by-week outline:
Other information:
Database entry:
Facility information:
 Student fieldwork information:
Make facility folder:
Print facility sheet:
Revised 2/18/2016
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