Occupational Therapy Fieldwork Assignment Information

Occupational Therapy Fieldwork Assignment

General Information

Site Name

Fieldwork Coordinator Name

Coordinator Phone Number

Coordinator Email

Location of Assignment/Where Student is to Report

Time Student is to Report to Site

Time Student is to Leave Site

Dress Code Expectations

Professional Casual Walsh Scrubs Walsh Polo with Pants

Additional Comments

Fieldwork Educator Information

Please submit this form for all FW educators who will be supervising students this semester.

On-Site Educator or Supervisor's Name

On-Site Educator or Supervisor's Phone Number

On-Site Educator or Supervisor's Email

Are you a licensed OT or OTA?

Yes No

Job Title

Highest Degree Earned

University Attended for Degree

Graduation Year

List All State Licensures

Number of Years Experience as a FWE

Additional Comments