WASHINGTON UNIVERSITY SCHOOL OF MEDICINE
PROGRAM IN OCCUPATIONAL THERAPY
FIELDWORK MANUAL
First Year Students
For MSOT16 and OTD17 students
2014 – 2015
With 2015 updates
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FIELDWORK PERSONNEL
Academic Fieldwork Coordinator (AFC)
Jeanenne Dallas, MA, OTR/L (JD)
dallasj@wusm.wustl.edu
office number: 314-286-1623; Room 1521
Fieldwork Administrative Coordinator
Leise Amann (Leise)
amannl@wusm.wustl.edu
office number: 314-286-1639; Room 1522
FIELDWORK EDUCATION
Fieldwork education is a crucial part of professional preparation and is best integrated as a
component of the curriculum design. Fieldwork experiences should be implemented and
evaluated for their effectiveness by the educational institution. The experience should provide
the student with the opportunity to carry out professional responsibilities under supervision of
a qualified occupational therapy practitioner serving as a role model. The academic fieldwork
coordinator is responsible for the program’s compliance with fieldwork education
requirements. (ACOTE, C.1.0)
LEVEL I FIELDWORK
The Accreditation Council for Occupational Therapy Education (ACOTE) 2011 standards for
occupational therapists states that:
The goal of Level I fieldwork is to introduce students to the fieldwork experience, to apply
knowledge to practice, and to develop understanding of the needs of clients.
Level I fieldwork shall be integral to the program’s curriculum design and include
experiences designed to enrich didactic coursework through directed observation and
participation in selected aspects of the occupational therapy process (C.1.8).
Qualified personnel for supervised Level I fieldwork include, but are not limited to,
occupational therapy practitioners initially certified nationally, psychologists, physician
assistants, teachers, social workers, nurses and physical therapists (C.1.0)
The Academic Fieldwork Coordinator (AFWC) will ensure that at least one fieldwork
experience (either Level I or Level II) has as its focus psychological and social factors that
influence engagement in occupation (C.1.7).
FWI OBJECTIVES
Level I fieldwork objectives for students in the Program in Occupational Therapy at
Washington University School of Medicine follow are listed below.
The student will (ACOTE 2011 standards are identified):
1. Adhere to the AOTA Code of Ethics during fieldwork education (ACOTE B. 9.1).
2. Develop personal and professional abilities, competencies, and behaviors on fieldwork.
3. Demonstrate effective oral communication skills and therapeutic use of self on fieldwork
with clients and health care professionals in group and individual settings (B.5.7)
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4. Develop client observational skills (B.4.1).
5. Experience the occupational therapy process and the role of occupational therapy in the
fieldwork setting (C.1.8).
6. Identify the purpose of common medical equipment/supplies in the fieldwork setting.
7. Perform medical record review, apply medical terminology, and maintain written records as
required of fieldwork setting (B.4.3, B.4.10).
8. Understand the occupations of individuals and apply the PEOP curriculum model in the
fieldwork setting (B.2.11, C.1.8).
9. Apply academic knowledge and practice skills learned in the classroom on fieldwork under
the supervision of a trained professional (C.1.9).
10. Identify personal knowledge and skills that need further development and direct further
learning and growth (B.9.4).
11. Begin to understand the role of other professionals on the team at fieldwork site
12. Identify interest areas for further fieldwork, research, and practice.
13. Demonstrate proficiency in medical terminology.
Additional Objectives for the MH FWI: *added in 2015
1. Identify the psychosocial issues of the clients you interacted with at the site. These may
be:
a. the symptoms of the person’s mental illness that are interfering with his/her
occupational performance
b. the psychosocial issues the client is experiencing due to a physical issue he/she is
experiencing
2. Identify and discuss what you did as an OT student to address the psychosocial issues of
the clients
Students complete Level I fieldwork experiences in a weeklong experience during the
spring semester of the first year and the fall semester of the second year of the
occupational therapy program. These experiences are designed to orient the student to
various practice settings and the types of clients served by occupational therapy. At no time
will FWI hours count towards FWII experiences.
Fieldwork I (FWI) and the Self Directed Experience Plan*
*2015 changed to Independent Learning Experiences
Each student will be placed (by the FW Administrative Coordinator) in 2 FWI experiences,
each being 40 hours long (typically concentrated during one week) during the spring semester
of the 1st year and fall semester of the 2nd year.
Each student will plan another 60 hours of self-directed experience time to be completed
throughout the 5 semesters of classes. These hours must be completed and documentation
turned in by April 1st of the 2nd year Spring semester. This pertains to both MS and OTD
students.
Per ACOTE (2011) standards, ALL experiences that are considered FWI must to be in sites
that the WUOT Program has an active FW contract with. Since self-directed hours are not
considered “fieldwork”, these experiences may be in sites that we do not have a contract.
This is for the FW Coordinator and the FW Administrative Coordinator to monitor.
Per ACOTE (2011) standards, an OT supervisor for FWI is preferred, but not required.
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FWI Requirements for the ASSIGNED FWI Experiences
40 hours of a Physical Disabilities/Rehabilitation experience
This requirement is intended to give all students exposure to a hospital or medical setting
while on FWI. A weeklong (or extended) FWI I in this area of practice will be scheduled for
students by the FW Assistant
A list of contract sites is available on the FW database. Students will have training early in the
first semester as to how to access and navigate the database (see page 6 -7).
Options include: hospitals – pediatrics or adult (acute inpatient, inpatient rehab), skilled
nursing facilities, outpatient, home health, etc.
Ideally, the FW Assistant will try to schedule this physical disability experience as the
student’s first FWI in the spring of 1st year.
20 hours minimum of a Psychosocial/Mental Health (MH) experience
There are two ways to fulfill this requirement:
1. A weeklong FWI scheduled by the FW Administrative Coordinator – this can be scheduled
in the spring of year 1 or fall of year 2. A weeklong FWI is 40 hours (this fulfills the 20 hour
minimum requirement).
2. IF this requirement is not completed as a weeklong FWI, the student will complete the
required 20 hours in one of the semesters during the curriculum. The student will identify
his/her preferences for a site from a list of given choices. The FW Administrative
Coordinator will assign students to a contracted St Louis site that has agreed to take
students for this experience.
A list of contracted sites for either of these options is available on the FW database. Students
will have training early in the first semester as to how to access and navigate the database.
As with all FWI’s, there may not be an OT on the site. An OT supervisor is preferred, but not
required for FWI. Many MH sites do not have an OT on site; the student will be supervised by
another professional.
Students will turn in FWI site/city preferences for the FW Administrative Coordinator to use
when scheduling the FWI week-long experiences. The students will be oriented to this form
and procedure early in the first semester of the curriculum.
A Professional Behaviors Document (PBD) evaluation completed by the supervisor of the
student will be required for the assigned FWI experiences. Other assignments will be listed in
the fieldwork course syllabus.
Self Directed Hours:
60 hours of experiential time to be completed throughout the 5 semesters of classes.
 These hours MUST BE completed by April 1st of the 2nd year Spring semester. There
will be NO exceptions granted.
Students will develop a Self-Directed Experience Plan, including learning goals, at the
beginning of the spring semester of the first year.
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This plan will be documented on the Self-Directed Experience Plan and Record (page 31).
It will be the student’s responsibility to report on the status of the Self Directed Plan each
semester.
 See the form for details on how this will be turned in.

Students will be oriented to this process during the first semester of the curriculum.
Students should plan for ~20 hours of Self Directed experiences in semesters 2 - 5 in
order to complete the requirement of 60 hours by the end of the curriculum.
Students will spend a minimum of 8 - 10 hours at the site in order to count the experience as a
Self-Directed Experience.
Some examples of experiences are volunteering in a community site for more hours over the
minimum required by the Theory course or the 20 hours MH FWI requirement, quad rugby
team, disabled sports associations, overnight camps counselor for camps focusing on specific
populations with disabilities or special needs, personal attendant for someone who is disabled,
etc. Overnight camps may count for all the 60 hours if approved on an individual basis by the
AFC. Some paid work may count towards the 60 hours if approved on an individual basis by
the AFC.
Approval of the Self Directed Plans
Students will complete their 1st year Self-Directed Experience Plan at the beginning of the
spring semester in the OT5610 FW course.
It is recommended to talk to the advisor or lab chair for guidance or ideas, but this is
NOT required.
There will be a due date set by the AFC – Refer to the OT5610 syllabus
Students will return the completed Self-Directed Experience Plan and Record form to the FW
Administrative Coordinator; the Academic FW Coordinator (AFC) will review the plan and will
bring any concerns to the attention of the student.
The FW Coordinator will have final approval authority for all Self-Directed Plans. Questions
from students should be directed to the AFC.
After the AFC has approved the Self Directed Plan, the plan will be returned to the student to
refer to and use at the end of the planned semester to record his/her experiences. These
plans may be adjusted as needed during the curriculum.
Documentation of the Self Directed Experiences
Students will record the time spent in self-directed activities using the Extended Fieldwork
Level I and Self Directed Experiences Tracking Grid (see page 18). It is recommended to
use one form per site (if at multiple places).
The site “supervisor” will sign to confirm that the student completed the hours. The AFC may
allow forms to be turned in without the signature if the supervisor is difficult to locate or not
realistic to get a signature.
The student will write a short statement to describe what was done at the site for each visit.
The student is required to write a short (1 page max) self-reflection paper describing how the
experience met (or did not) the goals that the student hoped to accomplish.
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The self-reflection and the tracking form are to be turned in to the FW Administrative
Coordinator. The forms will be due towards the end of the summer session so the FW
Administrative Assistant can make note of the students’ progress towards achieving the 60
required hours.
LEVEL I FIELDWORK SITE SELECTIONS
Site selection for the two one-week placements:
Washington University Program in OT has contracts with over 400 fieldwork sites around the
country. Sites include, but are not limited to hospitals, community agencies, schools, private
practices and outpatient programs. The Program in OT is NOT seeking new Level I or II
fieldwork sites at this time; students must pick from the sites available.
Accessing FW Information* UPDATED 2015
It is best to use Internet Explorer to access the FW information
From WUOT webpage (www.ot.wustl.edu):
Click on Education/Resources/For Current Students;
Log onto Citrix using your user name and password. The Domain is Medpriv
Launch the Desktop…you will then see desktop icons for various resources
Click on the Computer icon to access the Student drive
Click on Fieldwork the FW folder will be where you can find information about FW in general.
This is where the AFC will “file” away information that students need.
Click on FW Data Forms…each state will have a folder.
A Fieldwork Data Form is included in these folders, along with other information on the site.
The Fieldwork Data Form describes the level of experience of the supervising therapists,
types of clients served, models of practice, and methods of intervention. Students should
review the information and search the internet for other information about the site.
Instructions for Accessing the Fieldwork Database
Go to: http://www.ot.wustl.edu
Click on: Education; Click on Resources; For Current Students
Click on Citrix
If this link does not work, try this: https://wii.pcf.wustl.edu/Citrix/Medpriv/auth/login.aspx
Log onto Citrix using your user name and password. The Domain is Medpriv
Launch the Desktop…you will then see desktop icons
Click on the “Compass Access” Internet Explorer Shortcut / icon
Click on Favorites at the top menu
Click on “FileMaker Pro - FIELDWORK” to open the program
Log on:
Account Name: Student
Password: Explore1
*IF you have trouble accessing File Maker Pro through Citrix, you can try this link:
http://10.39.142.210/fmi/iwp/res/iwp_home.html
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The Fieldwork Student Menu Screen will open up.
1. For current reservations: click on the Level I 2015/2016 button or other pertinent field that
you want to check.
To review past reservations: click on Level I for prior years
2. To find a specific site by site name, city or state
 Go to the magnifying glass at the left / top of the screen (Find Mode)
 The fields on the screen will disappear
 Move the cursor to the field you wish to search, i.e. city, state, practice area
 Click on that field
 Type in the site name, city or state (whatever the field is that you are searching
 Move the cursor to the left of the screen and click on the “Perform Find” button
 Your search will finish in a moment or two. (You will know how many “hits” you have
by the number on the left side of your screen, stated “Found Set”)
3. To sort through your “found” files
 Find the notebook icon on the left or top side of the screen (with arrows)
 Click on the right / left arrows to scroll through the found set.
4. To find other information, follow the directions above and type in the correct field the
information you are looking for. For example: under benefits/housing, type “>0” and
“Perform Find” and all sites with information regarding housing will be found.
5. To find First Come First Serve sites, follow the directions above and type in FCFS in the
COMMENTS field. (This will be explained during the fall semester of first year).
6. REMINDER: look at the bottom of the screen to see if Level I or Level II is checked. IF
Level III is the only box checked…that is NOT an OT FW site, it is a Doctorate
Apprenticeship only site!
7. STUDENTS ARE NOT ALLOWED TO CONTACT FW SITES DIRECTLY!
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LEVEL I FIELDWORK POLICIES AND PROCEDURES
The Program makes arrangements for fieldwork placements with the designated contact staff
of each fieldwork site. An information packet including fieldwork objectives, student health
record, student assignments, procedures, evaluation forms and handouts related to objectives
is forwarded to the Fieldwork Educator at the site.
In the FW class in the spring semester of the first year students are oriented to fieldwork
objectives, procedures, and related protocols. Students are instructed to contact their
Fieldwork Level I Educator (after the placement has been made) to confirm pre-requisites,
arrangements regarding schedules, location, expected attire, etc.
PLACEMENT POLICY
The Program in Occupational Therapy will provide the student with fieldwork experiences in
settings that have been deemed appropriate for placement and that have expressed a
willingness to fulfill the responsibilities for Level I Fieldwork supervision. Students will only be
placed in sites that have a signed Affiliation Agreement (contract) with Washington University.
SITE SELECTION POLICY
Every effort will be made to offer students exposure to different types of clients in a variety of
practice settings. This is in effort to assist the student in achieving a level of comfort and to
integrate knowledge and skills effectively.
Students identify and rank their top three areas of interest for practice or pick their top four
sites and geographic areas for each FWI on a FW Preference Sheet distributed to the
students mid to late fall for the spring FWI and in late summer for the fall FWI. The form must
be turned in on time or the student will forfeit the right to indicate a choice for the semester.
RESERVATION REQUESTS
Students are NOT to contact a site requesting a placement for fieldwork Level I or Level II
unless given permission by the AFC.
If a student makes a direct request to a specific site for a personal placement through
any means without permission, that site will no longer be an option for that student.
FWI REQUIREMENTS
Students are responsible for meeting site specific requirements as outlined on the Fieldwork
Database and the site’s FW Dataform. Such requirements may include, but not limited to,
drug screenings, police background checks and CPR certification.
Students who do not fulfill these site-specific requirements will not be allowed to
attend fieldwork and will not pass the FW course.
WUOT covers standard pre-requisites required by FW sites:
 A 6 panel drug screen at the beginning of the curriculum – WUSM Student Health
 Drug screens over 6 panels needed for some FW sites – Barnes Care
o The FW Administrative Coordinator coordinates this
 CPR re-certification through the American Heart Association
o The WUOT Administration office coordinates this
 Annual TB tests and immunizations – WUSM Student Health
 Background check at the beginning of the curriculum – Certifiphi Background
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
o The WUOT Administrative office coordinates this
Updated background checks IF needed for FWII – Certiphi Background
o The WUOT Administrative office coordinates this
Standard fingerprinting (as needed) – WUSM Campus Protective Services
If a student gets any of these tests/checks elsewhere, they will be responsible for those costs.
Each student is responsible for transportation and housing expenses while on FWI and FWII.
If the student puts a specific city down on the Preference Form, we presume the student will
be able to reach any site in that city. The FW office is not responsible for arranging FW
placement around transportation or housing issues.
FWI DRESS CODE
Students are required to know and follow the accepted dress code for their site.
Appropriate Dress is MANDATORY while on FW or observing OT in various settings:
It is advised to wear COMFORTABLE clothing while on FWI:
 Layers (i.e. sweater over a short sleeved shirt) may be useful since temperatures in different
units vary widely.
 NO open toed shoes or clog type shoes – you must wear closed toed, closed heel shoes,
tennis shoes are acceptable in some locations (check this out with the site).
 Socks or other appropriate foot ware is required.
 NO denim of any kind (blue, black, etc.) unless allowed by the site.
 NO shorts or Capri type pants. Wear long, full length pants, but be mindful of the lengths – do
not wear pants that you are walking on the hems.
 NO shirts that show your stomach or back area when your arms are down to your sides or
raised above your head or when you bend over!
 NO thin strapped shirts, visible bra straps, low neck or revealing tops.
 Some sites require piercings to be removed while at the site and tattoos covered.
 When in doubt, think MODEST CLOTHING!!
 You must wear your OT school ID badge.
ATTENDANCE POLICY
Unless other arrangements are made, each student is expected to be on-site for 40 hours (or
what is considered full-time by the site). Students will follow the schedule of the fieldwork site;
40 hours are required, but in some cases fewer hours may be acceptable with the permission
of the AFC. In that case, students must perform at least 32 hours minimum.
Attendance at fieldwork is mandatory. Sessions missed for inclement weather, illness, etc.
must be made up. Failure to make up this time results in automatic failure of the course.
Emergency situations will be handled on a case by case basis.
Students must report to fieldwork as scheduled unless illness or extenuating conditions arise.
Students must report absences in advance to fieldwork site supervisor and inform AFC or
Fieldwork Administrative Coordinator the day of the absence.
If all hours scheduled for the FWI are not satisfactorily completed, the experience will be
considered a failure. Extenuating circumstances must be reviewed with the site Fieldwork
Educator and the AFC. It’s the students’ responsibility to ensure all hours are completed.
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Extended FWI: Extended Fieldwork I experiences require additional planning and time
commitments during the academic schedule. Students on an extended FWI will be expected
to complete 40 hours. The student and the site Fieldwork Educator schedule weekly times for
extended experiences (available spring of 1st year, and the fall semester during the 2nd year)
for students whose schedule allows. All extended experiences are within driving distance in
the St. Louis area. Any absences require contact with the student’s Fieldwork Educator and
reporting to the AFC. Every effort must be made to make up absences at the convenience of
the fieldwork site; therefore absences must be made up.
Students will use the “Extended Fieldwork Level I and Self Directed Experiences Tracking
Grid” (pg 18) to record time spent at the FW site.
ILLNESS OR INJURY WHILE ON FIELDWORK
If a student becomes ill or is injured while on fieldwork, the student is to seek medical attention
immediately. Our contract with each site ensures that they will arrange emergency medical
care while the student is on their site; however, the site is not responsible for the cost. Refer
to your Student Health Insurance manual for further coverage questions.
Once your situation has stabilized and your immediate family has been contacted, you must
notify the OT Program (the AFC) and Student Health. This is especially important in cases of
exposure to body fluids. The student, OT program and Fieldwork Educator will assist in
determining continuation of your fieldwork experience in cases of severe illness or injury.
FIELDWORK ASSIGNMENT POLICY
Each student is to complete all assignments for each fieldwork experience including those
assigned by the Fieldwork Educator, AFC, and instructors for other courses in the curriculum.
Submit all assignments on time to the appropriate party.
Students are required to keep a fieldwork journal during their experience. Refer to the
Fieldwork and Professional Competence syllabus for criteria/format.
Students may have assignments from other classes while on fieldwork. The fieldwork site
may have specific objectives and assignments for the student.
It is the students’ responsibility to complete all assignments in the designated time frame. If a
student is having difficulty completing the assignment, he/she should discuss this with the
appropriate party (Fieldwork Educator, Course Instructor, or AFC).
EVALUATION OF STUDENT PERFORMANCE ON FIELDWORK I
At the end of the fieldwork experience, the Fieldwork Educator will document the student’s
performance on the Fieldwork Professional Behaviors Document (see p.16-17). The
supervisor is encouraged to give ample feedback on this evaluation. The results are
discussed with the student, including performance-related strengths and areas in need of
further development. The student will return the Professional Behaviors Document to the AFC.
If problem areas are identified, discussion with the AFC and a remediation plan will follow.
If any time during the experience the student is concerned that a passing grade will not be
received, he or she should discuss immediately with supervisor and AFC.
Students will complete the “Student Evaluation of Fieldwork Experience: Level I” (pg 14-15)
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form about the fieldwork experience. This is exchanged and discussed with the Fieldwork
Educator during the performance review. The student will return this form signed by the FW
Educator to the OT Program following FW.
Minimum passing grades for Level I fieldwork:
Semester 2 Level I Fieldwork (OT5610):
“Meets Standards” performance on at least 60% of the items (min. of 22) and “Unsatisfactory”
performance on 0% of the items
Semester 3 Level I Fieldwork (OT5615):
“Meets Standards” performance on at least 80% of the items (min. of 29) and “Unsatisfactory”
performance on 0% of the items
CONTACTING A LEVEL I PLACEMENT
Concentrated fieldwork experience: Contact site at least three weeks prior to the FW week
or when the AFC or FW Administrative Coordinator has said to contact the site.
Extended fieldwork experience: Contact the site coordinator immediately upon receiving the
assignment. It is the student’s responsibility to set up the FW schedule with the site.
Determine a mutually agreeable time and day to attend fieldwork (this is worked around the
student’s class schedule).
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



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Ask for the contact person listed on the assignment form or the Student Coordinator
Introduce yourself, tell them what school you are from and confirm dates with the site’s
Fieldwork Coordinator/contact person.
Ask for the name of your supervisor for the fieldwork experience and the contact
information – email will probably be the best way to communicate.
Ask specifics for the fieldwork: parking, location of center, hours, dress code, etc.
Confirm requirements specific to that site: CPR certification, background
check, drug test, etc. These are listed for each site in the database and on the FW Data
Forms.
If you do not receive an answer via email in a week, try again OR call the site!
CRITERIA FOR CHANGING SITES AFTER CONFIRMATION
If a student cannot attend the fieldwork at the site they are placed at, the student must contact
the FW Administrative Coordinator or AFC immediately to explain the nature of the change
request. Requests for changes based on personal needs will be considered on an individual
basis. Proof of hardship may be required.
The following are examples of acceptable reasons for requesting a change in your confirmed
FWI site:
- Severe illness of family member
- Student health difficulties that require a specific accommodation
- Recommendation by physician
- Recommendation by CAPES
- Judiciary commitments
The following reasons will not be considered if requesting a change in confirmed FWI site:
- Student changed their mind
- Change in marital status (engagement or marriage)
- Needs of pets
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The site’s work schedule or location (driving distance) does not match student
preference
It is assumed that students will take into consideration all personal needs as well as all
financial and family responsibilities prior to identifying their fieldwork preferences (location or
site).
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ADVANCEMENT POLICY
Advancement to succeeding FW courses and FW Level II is dependent upon satisfactory
completion of the fieldwork experience and achieving the minimum score as identified on the
Professional Behaviors Document.
Failure to pass the FWI will result in a referral to the Committee on Academic and
Professional Evaluation of Students. No FWI hours will count towards FWII hours.
FIELDWORK DOCUMENTATION
Documentation returned to the FW Administrative Coordinator at the end of the fieldwork
experience includes:

Fieldwork Professional Behaviors Document,

Student’s Evaluation of Fieldwork Experience,

FW Journal (can be emailed)

Completed Tracking form (if on extended fieldwork. Refer to course syllabus for due
dates of these documents.
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HIPAA
Refer to http://secpriv.wusm.wustl.edu for complete information on HIPAA.
Every student has completed HIPAA training at WUOT and is to comply with the HIPAA
policies of the organization and Washington University while on Fieldwork Level I, II or OTD
Apprenticeship. Students violating HIPAA while on Fieldwork Level I, II or OTD
Apprenticeship will face sanctions from the organization and the university. The level of
violation of HIPAA will be determined by the organization and WUOT.
Students found in violation of HIPAA will be brought to the CAPES committee and will face
disciplinary action as determined by WUOT and the CAPES committee.
Sanctions for Non-Compliance with HIPAA Policies
Washington University and its member organizations (collectively, “Washington University” or
“WU”) are committed to conducting business in compliance with all applicable laws,
regulations and WU policies. WU has adopted this policy regarding sanctions for violations by
workforce members of the Health Insurance Portability and Accountability Act of 1996
(“HIPAA”).
This Policy covers all workforce members within Washington University covered entity
component parts whose actions or failures to act violate WU HIPAA policies. Workforce
members include employees (both faculty and staff), appointees, volunteers, trainees
(includes OT students) and other persons whose conduct, in the performance of work for
Washington University, is under the direct control of the University whether or not they are
paid by the University.
Sanctions for violations of HIPAA policies may include, without limitation, verbal counseling,
written warning, suspension, and discharge. Sanctions may also be applied for failure to
report a known or suspected HIPAA violation.
Factors in determining appropriate disciplinary action may include, but are not limited to:
 Whether the breach was intentional or inadvertent

The nature of the breach, including whether the breach involved specially protected
information such as HIV, psychiatric, substance abuse, or genetic data

The magnitude of the breach, including the number of patients and the volume of
protected health information accessed or disclosed

Workforce member’s motive in accessing or disclosing protected health information

Whether the workforce member has committed prior HIPAA violations

Workforce member’s response or conduct during investigation

Harm to the breach victim(s)
Investigation and Disciplinary Process:
Potential violations of the WU HIPAA Policy should be reported to the WU HIPAA Privacy
Office. The HIPAA Privacy Office will notify the HIPAA Security Office if a violation of a HIPAA
Security Policy is involved.
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A workforce member who becomes aware of a potential violation should immediately notify
his/her supervisor and/or the HIPAA Privacy Office.
Reports may also be made anonymously to the HIPAA Privacy Office (866-747-4975) or the
WU Compliance Hotline (314-362-4998).
Upon notification of a potential violation of a WU HIPAA Policy, the HIPAA Privacy Office will
investigate, review and assess the alleged violation. The investigation may necessitate,
among other things, workforce member interviews, computer audit trails, telephone log
reviews, etc. The HIPAA Privacy Office will determine whether and what
sanctions are appropriate in consultation with relevant administrators from the workforce
member’s department or other business unit, Human Resources and/or the Office of the
Executive Vice Chancellor & General Counsel, and the HIPAA Security Office if the matter
involves a breach of the HIPAA Security Policy.
Disciplinary actions will be documented in writing and maintained in the appropriate personnel
record. Disciplinary action may be appropriately delayed if the action could adversely affect or
compromise patient care.
Last Revision Date: October 7, 2010
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STUDENT EVALUATION OF FIELDWORK EXPERIENCE: LEVEL I
The Student Evaluation of Fieldwork Experience is an important tool for the fieldwork
instructor, faculty and other students. This evaluation provides information vital to each
program. Information from the student is one method utilized in evaluating the effectiveness
of academic preparation as well as the value of the fieldwork learning experience.
AGENCY NAME:__________________________________________________
AGENCY ADDRESS:_______________________________________________
_____ CONCENTRATED week
_____ EXTENDED EXPERIENCE
_____ Spring First Year
_____ Fall Second Year
1.) Describe the orientation to the program, its facilities and staff? Was this adequate?
Any suggestions to offer?
2.) How were you oriented to the Level I student responsibilities? Was this adequate?
Any suggestions to offer?
3.) Describe the treatment approaches demonstrated in this program.
4.) Describe the client population that you observed.
5.) Supervision was provided by (OT, PT, Social Worker, etc.)
6.) Describe the level of interaction with your supervisor. Was this adequate to meet
your learning needs?
7.) Were you adequately prepared by the Program to meet the objectives of this fieldwork?
 If yes, what courses or information was most helpful

If no, why not and what would have been helpful
15
STUDENT EVALUATION OF FIELDWORK EXPERIENCE: LEVEL I
8.) Rate this fieldwork site, based on your personal experience
1
2
3
4
5
6
7
8
9
poor
10
excellent
9.) Rate the supervision you received, based on your personal experience
1
2
3
4
5
6
7
poor
8
9
10
excellent
10. Would you recommend this site to another student? Why or Why Not?
ADDITIONAL COMMENTS:
Fieldwork Supervisor:__________________________________________________
Signature
Date
Student: ________________________________________________________
Signature
Date
16
FW Professional Behaviors Document
The student exhibits:
Meets Standards
Personal Integrity
1
2
3
4
Displays personal honor and integrity.
Demonstrates dependability and reliability.
Follows the AOTA Code of Ethics.
Respects authority and follows the chain of command.
Respect of Others
5
6
7
8
9
Respects diversity.
Demonstrates empathy and support of others.
Demonstrates awareness of how behavior affects others.
Demonstrates respect of others' values and beliefs.
Demonstrates appropriate etiquette.
Time Management & Organization
10
11
12
13
14
Attends regularly and on time.
Keeps time commitments or notifies in advance.
Acts proactively, plans ahead, proposes solutions.
Prioritizes tasks and commitments.
Demonstrates preparedness.
Personal Responsibility for Growth
15
16
17
18
19
20
21
Embraces responsibility for behavior and learning.
Demonstrates awareness of strengths and weaknesses.
Display an appropriate level of confidence.
Demonstrates flexibility in coping with change.
Seeks feedback and guidance to improve.
Uses feedback to modify behavior.
Manages stressors in positive and constructive ways.
Interpersonal Communication Skills
22
23
24
25
Listens to others' opinions and disagrees with tact.
Seeks clarification as needed.
Handles conflict constructively.
Uses appropriate verbal and non-verbal communication.
Cooperation & Collaboration
26
27
28
29
Contributes full effort to achieve team goals.
Pools resources and works efficiently within a group.
Is proactive and anticipates needs of others.
Assists with resolution of problems.
Professional Communication Skills
30 Participates thoughtfully in discussions.
31 Is attentive and aware of verbal and nonverbal behaviors.
32 Communicates in a concise manner.
33 Demonstrates correct grammar, spelling, punctuation.
Adherence to Policies
34 Adheres to laws, such as HIPPAA and confidentiality.
35 Follows OT Program guidelines on dress and hygiene.
36 Conforms to safe work standards and precautions.
17
Needs
Improvement
Unsatisfactory
For any item rated "Unsatisfactory" or "Needs Improvement",
Please write an example of the behavior should be included below, with recommendations or goals.
Item # and Example:
Recommendation or Goal:
Item # and Example:
Recommendation or Goal:
Item # and Example:
Recommendation or Goal:
Item # and Example:
Recommendation or Goal:
Comments:
Print supervisors name:
Preparer's Signature:
Date
Student's Signature
Date
Rev. 08/10
18
Extended Fieldwork Level I and Independent Learning Experiences Tracking Grid
Washington University School of Medicine
Program in Occupational Therapy
Student Name: ___________________________________
Site: ___________________________________________
Supervisor Name (please print):_____________________________________
This form is to be used for extended FWI experiences including MH FWI and
Independent Learning Experiences.
Date
Number of
Hours
BRIEF description of what you did
during the time spent at the site
Total:
I confirm that the student completed the hours and activities as recorded above.
Supervisor’s signature:
_____________________________________________
Supervisor
________________
Date
The student is required to TYPE a short (1 page max) self-reflection paper describing how
this experience met (or did not) the goals that the student hoped to accomplish.
For MH FWI, refer to the objectives on page 3 and reflect on the objectives.
The self-reflection and this tracking form are to be turned in to the FW Administrative
Coordinator
19
GENERAL FIELDWORK
POLICIES AND
PROCEDURES
FWII
INFORMATION
20
LEVEL II FIELDWORK OBJECTIVES FOR WASHINGTON UNIVERSITY
Fieldwork Level II is an integral part of the OT educational experience. It is during this time that
the student gains the opportunity to operationalize their knowledge and be mentored in the
process. It is also the first time the student has responsibility for their own clients in which they
demonstrate behaviors and ethical decision-making and use the evidence available of person,
environment and occupational factors that help clients achieve their own goals. It is our
objective for the students to engage in and demonstrate the capacity to practice in ways that
support their clients in achieving quality of life through occupation. The following objectives
should set the tone for the fieldwork experience.
Students will (ACOTE 2011 standards are identified):
1. Demonstrate the ability to perform assessment and treatment planning processes
consistent with the AOTA Practice Framework using the Models of Practice consistent with
their educational preparation (ACOTE B.4.1, B.4.2, B.4.3, B.4.4).
2. Administer and interpret occupational performance based assessments at the individual
outcome, program evaluation and program development levels in a skillful manner (B.4.4,
B.5.1, B.7.5, and B.7.6).
3. Use evidence to inform practice on a consistent manner; including evidence based on
experience, expert practitioners, from controlled studies, and from descriptive literature
(B.8.3, B.6.6).
4. Work collaboratively with team members and occupational therapy assistants to plan,
implement, and terminate interventions that address the occupational goals of the client
(B.4.5, B.5.22, B.5.25. and B.5.27).
5. Implement interventions centered on occupation, participation and environment as clientcentered care is planned and implemented (B.5.0, B.5.1).
6. Provide services focused on consumers and family to enable the client’s occupation and
maximizing occupational performance once discharged (B.5.28).
7. Advocate for those who may be vulnerable or at risk with secondary conditions (B.2.9).
8. Use occupational histories to create occupational profiles to guide client-centered care
(B.4.4).
9. Demonstrate a sensitivity to and inclusion of culture in the design of interventions (B.4.7).
10. Plan and implement assessment and intervention plans that demonstrate a balance of the
person, occupation and environmental factors (B.5.1, B.5.2).
11. Transition clients from one service level to the next to insure an outcome of full
participation and well being in addition to occupational performance goals (B.5.25, B.5.29).
12. Document occupation-based care plans, progress notes, goals and knowledge of billing
methodologies that support occupational-based practice (B.4.10, B.5.32).
13. Treat a full client caseload, as defined by fieldwork site, by the end of experience.
14. Submit correct and complete documentation in a timely manner, according to policies and
procedures of fieldwork site.
15. Consistently report to site on time.
16. Follow all policies and procedures as instructed by the fieldwork site and Washington
University Program in Occupational Therapy.
17. Demonstrate initiative when exploring new learning opportunities.
18. Actively participate in the supervisory process.
19. Utilize treatment approaches that demonstrate in depth knowledge of the various frames of
reference in Occupational Therapy practice.
20. Demonstrate entry-level competencies for the practice setting.
21. Demonstrate professional behaviors consistently.
22. Achieve all additional objectives set by the specific fieldwork site.
21
REQUIREMENTS FOR LEVEL II FIELDWORK & DOCTORAL APPRENTICESHIP
Each MSOT student must successfully complete 2 (12 week) Level II Fieldwork experiences
in order to complete the requirements for graduation from the Washington University Program
in OT.
Each OTD student must successfully complete 2 (12 week) Level II Fieldwork experiences
and one 16 week (640 hours) Doctoral Apprenticeship experience in order to complete the
requirements for graduation from the Washington University Program in OT.
MSOT and OTD students may complete an optional third Level II Fieldwork experience
(common sites are National Institutes for Health and AOTA).
The Level II fieldwork & Doctoral Apprenticeship experiences are credited courses (6 credit
hours each). All MSOT or OTD Academic work (including papers) MUST be completed and all
course grades are to be entered prior to starting FWII experiences. Failure to do so will result
in the student not being able to begin FWII on schedule.
FWII experiences should be in two different practice areas and across the lifespan. Typically
the 2 experiences are in two different facilities, but can be in the same facility IF the two
experiences are in two different practice areas. The FWIIs cannot be in more than 4 different
settings per ACOTE standard C.1.12. (2011).
Prerequisites for Fieldwork Coursework
 Level II Fieldwork: Must successfully complete all first, second year and 3rd year (for
OTD students) coursework, including all Masters or Doctoral Project requirements,
prior to first Level II experience.


Doctoral Apprenticeship: Must successfully complete the two Level II fieldwork
experiences (OT 593A & B) and all third year coursework, including all Doctoral Project
requirements and Competency requirement prior to the Doctoral Apprenticeship
experience.
Exceptions to the timing of the second FWII and Apprenticeship will only be made as
developed and approved by the Associate Director of Professional Programs.
OT593A Fieldwork II
This course provides fieldwork experience under the supervision of an occupational therapist.
Students’ participation includes in-depth experience in delivering occupational therapy
services to clients including evaluation, treatment and intervention. Students have the
opportunity to practice in a variety of clinical or community based settings. During the
fieldwork process, students are expected to assume increasing responsibilities related to
patient or client care. The fieldwork experience is designed to promote clinical reasoning,
professionalism and competency. Duration is 12 weeks.
OT 593B Fieldwork II
This course provides a second fieldwork experience under the supervision of an occupational
therapist. Students’ participation includes in-depth experience in delivering occupational
therapy services to clients including evaluation, treatment and intervention. Students have the
opportunity to practice in a variety of clinical or community based settings. Because this is the
second of two fieldwork II experiences, students are expected to build on their first fieldwork
and assume increasing responsibilities related to patient or client care. The fieldwork
22
experience is designed to progressively build competencies in clinical reasoning,
professionalism and entry-level skills. Duration is 12 weeks.
OT 793C Doctoral Apprenticeship (OTD students only)
This course provides a customized doctoral experience specific to the OT doctoral pursuit of
the student. Students may participate in research, policy, clinical practice*, advocacy,
teaching, etc. Students are expected to achieve specific goals established by the student, the
site supervisor, and the doctoral chair. Duration is 16 weeks (640 hours).
*If pursuing a clinical experience, the ACOTE standards for a FWII have to be followed
and a clinical contract has to be made with the site.
Timeline Requirements
All students must successfully complete the required Level II Fieldwork and/or Doctoral
Apprenticeship experiences within 12 months of completing academic coursework.
Failure to successfully complete the Level II Fieldwork and/or Doctoral Apprenticeship
experiences within the 12-month period will result in dismissal from the Program.
The Doctoral Chair, student and the AFC will coordinate efforts to ensure that the FWII and
the Apprenticeship is completed by the December date to qualify for graduation.
 This may mean adjusting the 2nd FWII dates to accommodate for the 16 weeks of
Apprenticeship; the Doctoral student staying at WU to work in his/her Doctoral lab for
some time to count towards Apprenticeship dates prior to the 2 nd FWII;
 OR another acceptable means of completing the required weeks before the end of the
year.
Unforeseen circumstances may require a Leave of Absence or remediation plan that will allow
the 12-month time frame to be extended. The Committee on Academic and Professional
Evaluation of Students (CAPES) will determine the impact of a Leave of Absence on the 12month time frame for completion of the Level II Fieldwork and/or Doctoral Apprenticeship
experiences. A Leave of Absence during Fieldwork must be approved by the CAPES. Refer to
Student Handbook for further information.
LEVEL II FIELDWORK POLICIES AND PROCEDURES
OFF SCHEDULE STUDENT PLACEMENT POLICY
From time to time some students may be off the “regular” fieldwork schedule for either Level I
or Level II placements. This may occur because of individual student need and/or by design
of their academic program. “Off-schedule” is defined as those experiences occurring at a time
other than the pre-designated times identified at the beginning of each academic year
(optional 3rd Level II experiences are included in this definition).
If a student has been placed “off-schedule,” the scheduling of their fieldwork placements will
be:
Level I: Students will complete the Level I Fieldwork Preference Sheet and the FW
Administrative Coordinator will request off schedule placement from fieldwork site. Specific
timeframes, geographic areas and practice areas are not guaranteed. The Program will
attempt to accommodate student requests, but the student may need to complete the
fieldwork experience in areas/sites not requested.
23
Level II and Doctoral Apprenticeship: If a student is unable to perform Level II Fieldwork
during the prearranged dates, the AFC will request off schedule placement from the student’s
preferred sites. This is automatically scheduled (mid- May to mid-August) for the first Level II
for doctoral (OTD) students. The Program will attempt to accommodate student requests, but
the student may need to complete the fieldwork experience at alternative sites if the dates
requested won’t work for the site. Many fieldwork sites prefer to follow the AOTA’s suggested
Level II Fieldwork timelines, but some sites will make exceptions for the dates of the
placement. Any change in the timing of the Doctoral Apprenticeship will be coordinated
between the FW office and the student’s doctoral mentor.
REQUESTS TO CHANGE THE TIMING OF LEVEL I AND LEVEL II
All requests for changes in the Level I experience are made directly to the AFC.
Students are not to contact sites individually to request a change unless authorized by
the AFC.
Level I: Level I concentrated experiences are scheduled by the FW office and published
annually on the Academic Calendar.
Students will complete their fieldwork at the pre-scheduled times unless:
1.) They meet the criteria for changing sites outlined previously
2.) A site has requested students during the spring break or
3.) The change in time is deemed necessary by the AFC.
Level II / Apprenticeship: Students may request to have the dates of their scheduled Level II
or Apprenticeship experience modified.
Requests should be submitted in writing (email) to the AFC and should include:
1.)
The name of the student
2.)
Date of the request
3.)
Requested dates to be changed (beginning and ending date)
4.)
The name of the Level II program assignment
The Program will contact the site for the student OR give the student permission to contact the
site and request the date modification.
It is the fieldwork site’s prerogative to change the date of the experience or deny the
request. The student will be notified of request acceptance or denial. IF the student has been
the person in contact with the site, the student will inform that the FW office of the correct
dates for the fieldwork.
ACCOMMODATIONS ON FIELDWORK
Students with disabilities who require accommodations need to work with the AFC well in
advance of the Fieldwork I and II placements to identify the specific reasonable
accommodations needed in the fieldwork setting.
Fieldwork placements will be made in sites that the FW office feels can meet the student’s
accommodation needs. Students will be responsible for disclosing the disability to the site
and to make the request for accommodations. The FW office will assist the student and the
site as possible.
To learn more about the student and the program’s responsibilities, refer to the Student
Manual on the Policy for Students with Disabilities
24
If new needs arise on fieldwork that suggest further accommodations are necessary, the
student should request these accommodations from the fieldwork site and notify the AFC.
INTERVIEWS PRIOR TO LEVEL II PLACEMENT
Several FW sites require an in-person or telephone interview prior to agreeing to take the
student for a Level II placement.
It is the student’s responsibility to arrange and complete these interviews in the timeline
required for placement.
The Fieldwork Assistant will communicate with students to make sure the interviews are
arranged.
The student will set up and complete telephone interviews independently. Students should
present themselves appropriately and be prepared for the interview. Students who do not
complete the required interview will not be considered for placement at that site.
NEW LEVEL II CONTRACT REQUEST
NEW FIELDWORK CONTRACT REQUESTS WILL NOT BE ACCEPTED!
CONTACT WITH FW SITES
Students are NOT allowed to contact FWII sites for any reason unless approved by the AFC.
The AFC will be cc’d on all correspondence that the student has with the site after approval is
granted.
FIRST COME – FIRST SERVE FIELDWORK SITES
Sites that prefer to place Level II fieldwork students on a First Come-First Serve (FCFS) basis
are noted on the FW Database in the comments section of the sites by the notation “FCFS”.
Students should check the database late in the fall semester to determine if any of the sites
he/she would like to go for FWII are listed as a FCFS site.
The student will complete the F-1, F-2 and F-3 forms by the due date (early in the spring
semester) to request a FCFS FWII placement. If only one student requests a particular site,
that student will be placed there (as long as there is still an available spot at the facility).
*See below for details. This procedure will be explained by the AFC in the fall semester of the
first year.
NOTE: If the site(s) you are considering for a Level II FW is not listed as a FCFS site, you will
not complete the FW forms and turn in requests until the fall semester of your second year
(see General FW Level II Match Process on page 25).


First Come First Serve Level II Fieldwork Procedure
Late in the fall or early in the spring semester of the first year and the fall semester of the
second year students should conduct a search in the FW database for sites that have
requested and/or have a history of taking Level II students a year in advanced on a First
Come First Serve (FCFS) basis. See FW database instructions on page 7.
Students should review the information on the sites available in the site’s folder, discuss
with family, significant others, etc. before submitting requests
25







Students must complete all FW II placement forms (F1, F2, F3) and review with their
academic advisor (1st yr MS and OTD students; 2nd yr MS students) or doctoral chair (2nd
yr OTD students)
Turn in requests by due date given by the AFC (typically early in the spring semester).
If only one student is interested in a site, that student automatically gets that site if the site
is available and agrees and if approved by the students faculty mentor.
If more than one student is interested in a site, a name will be picked at random for
placement.
If a student submits for more than one site, and receives a placement, consideration will be
given to other students prior to a second placement for that student.
If an interview is required, the student must set the interview up and successfully complete
it prior to confirmation of placement. The placement will be considered “pending” until the
interview is completed and the site informs us that they will accept the student.
FCFS sites may be requested after the due dates, we will contact the site to see if the
placement is available.
FCFS RULES
 Students cannot cancel, FOR ANY REASON, a site chosen through the FCFS process.
 This process is ongoing – meaning the forms deadline given is when we start
placements, but students can turn in requests anytime after that date until midSeptember.
 Requests received by the due date will be given priority.
CONSIDERATIONS
 Think carefully about your choices; be sure that this is what you want because there are no
changes unless made by the site.
 Think about emotional support available in the area, finances, etc. prior to making your
decision.
 A change in marital status or planned housing or transportation in the city of your choice
will not be grounds for changing a FCFS placement.
 Search the database for FCFS notations every year as sites may be added to this category
each semester.
PLACEMENT PROCESS FOR LEVEL II FIELDWORK
GENERAL FIELDWORK LEVEL II MATCH PROCESS
 During the summer session, the AFC will send instructions to the students (both 2nd year
and 3rd year students) to begin looking at FWII sites. Students will be given a deadline to
turn in the F forms, typically early October.
 MSOT students and second year OTD students are assigned random numbers in the fall
that determine the ordering of the match.
 The first Level II is assigned to students by increasing match numbers and second Level II
is assigned to students by decreasing match numbers.
 FCFS students are placed into the random order of matches, not separated out
 FCFS students will be placed for their remaining fieldwork in the first round of matches,
they will not be held until second round.
 Second year OTD students are in the general Level II match for 3rd quarter. Sites will be
contacted to see if they are available for an off schedule placement due to the early return
26


to classes in the fall. The individual site determines if they can accommodate the adjusted
Level II dates
Third year OTD students will be assigned a number and placed for their 2 nd Level II prior to
placing MSOT and second year OTD students.
 The placement dates may have to be adjusted to accommodate timing of the OTD
Apprenticeship. This will have to be communicated with the AFC and the FW
Administrative Coordinator
rd
3 year OTD students will work with their Doctoral Chair to design a 4th quarter Doctoral
Apprenticeship experience that fits within their study concentration.
The following procedure will be followed to ensure a good match for the Level II Fieldwork
experiences and comply with the ACOTE standards.
Level II Fieldwork Goals & Learning Needs: Form F-1
Choosing a Level II setting which meets the student’s entry-level skill set and can provide an
environment which meets the student’s learning needs and accommodations is critical to a
successful experience and clinical growth. Students must identify their learning needs, skill
development needs, and accommodations by honest self-reflection and record these on Form
F-1. Students must identify their fieldwork goals. The fieldwork goals should be recorded on
Form F-1. This form will be used in picking fieldwork sites and should be brought to a meeting
with the advisor/doctoral mentor for fieldwork site approval (see Form F-3 below).
Advisor / Doctoral Chair Level II Approval Document: Form F-2
After choosing several sites which meet your learning needs, skill development needs,
accommodation needs, fieldwork goals, and are from a variety of life span and settings, set up
a meeting with your research chair to discuss your choices. Do this early!
List the sites on Form F-2 and include a short reason each site is a good fit. Bring site printouts from the FW Data Base, the site folder, information from the internet on the site, and
Forms F-1, and F-2 to the meeting with your mentor. Information can be emailed to the
mentor ahead of time for the mentor to review. Present all of this information to your mentor
and discuss your choices thoroughly. The advisor or doctoral chair will rate the fit of each site
and provide brief comments on Form F-2. If there are not enough sites that are deemed a fair
or good fit by mentor, the student must find new sites, meet with advisor/doctoral chair and
complete Form F-2 again. Set up your initial meeting early enough to allow for this additional
meeting time if needed.
Most sites require that the Pediatric FWII placement be the second of the two FWII
placements. This is also strongly suggested by the WUOT program.
Level II Preference Form: Form F-3
The student lists their placement preferences in rank order for the 3rd quarter (June to
September) FW and the 4th quarter (September to December) FW on Form F-3, including
previously secured FCFS sites. Only sites deemed a fair or good fit by faculty mentor can be
placed on this form. Sites must represent a variety of life span ranges and treatment settings.
If you are turning in an F-3 form with choices for both quarters, identify which quarter you want
placed in first.
27
Level II Fieldwork Goals & Learning Needs: Form F-1
Student Name:_________________________________ Date:_____________
Think about what you want to accomplish on your FWII’s. What do you need on your FWII’s?
How do you learn best? What type of supervision works best for you?
The following are my learning needs, skill development needs, and accommodation or special
needs for FW II:
1._______________________________________________________________
2._______________________________________________________________
3._______________________________________________________________
4._______________________________________________________________
5._______________________________________________________________
6._______________________________________________________________
The following goals (min. of 3) represent my Fieldwork Level II priorities in rank order:
1._______________________________________________________________
________________________________________________________________
2._______________________________________________________________
________________________________________________________________
3._______________________________________________________________
________________________________________________________________
4._______________________________________________________________
________________________________________________________________
5._______________________________________________________________
________________________________________________________________
Student’s Signature________________________________Date______________
I reviewed these with the student and have made my recommendation:
Advisor / Doctoral Chair ____________________________ Date______________
28
Faculty Mentor Fieldwork Approval: Form F-2
Student Name:____________________________________Date:_____________
Student’s Level II fieldwork placement choices & reasoning of fit with Goals/Learning Needs.
Bring site information to meeting with faculty mentor!
1. Site Name/Location:___________________________________________________
Student’s Reason for choosing site: _________________________________________
______________________________________________________________________
2. SiteName/Location:____________________________________________________
Student’s Reason for choosing site: _________________________________________
______________________________________________________________________
3. Site Name/Location: ___________________________________________________
Student’s Reason for choosing site: ________________________________________
______________________________________________________________________
4. Site Name/Location: ___________________________________________________
Student’s Reason for choosing site: _________________________________________
______________________________________________________________________
5. Site Name/Location: ___________________________________________________
Student’s Reason for choosing site: _________________________________________
______________________________________________________________________
6. Site Name/Location: ___________________________________________________
Student’s Reason for choosing site: _________________________________________
______________________________________________________________________
Students Signature_________________________________
29
F-2 continued
Note to faculty: Student should bring information on each site to the meeting!
Faculty Mentor’s Approval & Comments for each site:
Site #1:
Good Fit
Fair Fit
Poor Fit
Comments:____________________________________________________________
_____________________________________________________________________
Site #2:
Good Fit
Fair Fit
Poor Fit
Comments:___________________________________________________________
_____________________________________________________________________
Site #3:
Good Fit
Fair Fit
Poor Fit
Comments:____________________________________________________________
______________________________________________________________________
Site #4:
Good Fit
Fair Fit
Poor Fit
Comments:____________________________________________________________
_____________________________________________________________________
Site #5:
Good Fit
Fair Fit
Poor Fit
Comments:___________________________________________________________
____________________________________________________________________
Site #6:
Good Fit
Fair Fit
Poor Fit
Comments:___________________________________________________________
____________________________________________________________________
Additional Comments:___________________________________________________
_____________________________________________________________________
Advisor / Doctoral Chair’s Signature____________________
30
Date______________
Level II Preference Form: F-3
Student Name: ________________________________ Date: _____________
List your Level II Fieldwork choices in rank order for each FW experience.
*OTD students need to only choose 3rd quarter sites.
June to September (3rd quarter)*
1.__________________________________________________________
2.__________________________________________________________
3.__________________________________________________________
4.__________________________________________________________
5.__________________________________________________________
September to December (4th quarter)
1.__________________________________________________________
2.__________________________________________________________
3.__________________________________________________________
4.__________________________________________________________
5.__________________________________________________________
Student’s Signature____________________________________Date_________________
31
FWI and Self-Directed Experience Plan and Record
DUE DATE: _______ (early in semester for OT5610)
Student Name: _________________________
Date: ________________
FWI week - Spring / Fall
 Each student will turn in the FWI Preference form to the FW Administrative Coordinator (Leise Amann) to be
placed in this experience
 This will ideally be a physical disabilities or a psychosocial/mental health experience assigned by the FW Assistant.
____ I turned in my FWI Preference form to Leise Amann
My assigned FWI site is: _____________________________________________________
Student Agreement: I plan to fulfill my Self-directed experiences according to this plan. I will
record progress towards the fulfillment of requirements each semester and submit changes of
plan to the AFC. I will keep a record of the hours and my activities in my Self Directed Plan.
Spring / Summer _______
Learning Objectives / Goals for my Self Directed experience(s):
This is why I want to participate in these experiences and what I hope to accomplish or learn.
I will reflect upon these goals in my end of the semester reflection.
1.
2.
3.
____ Self-Directed experiences – list the experiences you plan to pursue to count as selfdirected experience:
(i.e. volunteer experiences, extra time spent in agencies from Theory class, time spent in a site at home over the break, etc.)
1.
2.
3.
Student Signature: ___________________________
Student will forward a signed copy of this form to the FW Administrative Coordinator
All plans have to be approved by Jeanenne Dallas (JD).
32
JD APPROVAL ______
PLEASE PRINT THIS PAGE, SIGN AND
Bring to the Mandatory FW Orientation session at Oct. 1, 2014
Washington University School of Medicine
Program in Occupational Therapy
I, ________________________________, have read and understand the Fieldwork Policies
as outlined in the Fieldwork Manual. I agree to follow and take responsibility for my actions as
outlined in the Fieldwork Manual.
If I choose to take other courses of action than those outlined, I will accept full responsibility
for any consequences as a result of those actions.
____ I have downloaded a copy of the FW Manual for my reference throughout the year.
____ I know that I can find this FW manual on the Student Drive and on the WUOT
website.
Student Signature
Date
33