Level II Fieldwork Request

Level II Fieldwork Request Form

Walsh University is requesting placement of Master of Occupational Therapy students for 12-week LEVEL II Fieldwork. This group of students will be completing two separate full-time fieldworks: “Spring” from January 18, 2021 – April 9, 2021 and “Summer” from May 10, 2021 – July 30, 2021.

Please complete this form and return it by March 27, 2020. If you have any questions about any of these placements, please contact Michele Tilstra at mtilstra@walsh.edu or call 330.490.7410.

Facility Information

Name of Facility

Primary Contact

Address

City

State

Zip Code

Email Address

Phone Number

Fax Number

Dates of Experience for Level II SPRING (January 18, 2021 – April 9, 2021) Offers

Number of Students for SPRING

Type of Experience for SPRING (check all that apply if known)

If other/mix (for SPRING), please describe.

Clinical Instructor for SPRING (if known)

General Information for SPRING (i.e. split placement, number of supervisors, type of acute or rehab setting, pace of setting, specific location if at a different facility)

Dates of Fieldwork Experience for Level II SUMMER (May 10, 2021 – July 30, 2021) Offers

Number of Students for SUMMER

Type of Experience for SUMMER (check all that apply if known)

If other/mix (for SUMMER), please describe.

Clinical Instructor for SUMMER (if known)

General Information for SUMMER (i.e. split placement, number of supervisors, type of acute or rehab setting, pace of setting, specific location if at a different facility)