Fieldwork Data Form Occupational Therapy

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Fieldwork Data Form Occupational Therapy Powered By Docstoc
					                                    FIELDWORK DATA FORM
                                                                         DATE:          02-29-2008

This form refers to Level II fieldwork experience.
Length of fieldwork: 12 weeks for second Level II placement, 8 weeks for third Level II placement
Will Ac cept x Full-time Student       Part-time Student      1st Placement       x               2nd Placement x
3rd Placement
Name of Center: The Children's Hospital of Philadelphia
Address: 34th Street and Civic Center Boulevard
City/State/Zip: Philadelphia, PA 19104-4399
Center Phone: (215) 590-1000                           Center E-Mail Address
Fax Number: (215) 590-7661                             Center Website: www.chop.edu
Director: Erika Mountz, MBA, OTR/L
Person Responsible for Le vel II Fieldwork Program: Julie M. Buxton, MS, OTR/L
Credentials: MS, OTR/L Telephone: (215) 590-2434 E-Mail Address: buxton@email.chop.edu

Person Responsible for Le vel I Fieldwork Program: April Andrescavage, OTR/L
Credentials: OTR/L      Telephone: (215) 590-7467 E-Mail Address: andrescavage@email.chop.edu
# of Staff : 40+ OT (s), 3 Support Staff       Approximate # of agreements with schools: 25

Accreditation by: Joint Commission for the Accreditation of Hospital Organizations                                  Date: 20

                                               GENERAL INFORMATION

            SETTING                                           DESCRIPTION OF SPECIALTY
   x     Hospital                 (e.g. Acute Inpt, Outpt, Rehab Unit) All areas in pediatrics
         School                   (e.g. Public School System)
         Community Agency         (e.g. Psycho-Social Program, Homeless Shelter)
         Private Practice         (e.g. Pediatrics, Psych, Home Health)
         Residential Program      (e.g. Developmental Delay, Mental Retardation)
         Nursing Home             (e.g. Rehab Unit, Long Term Care)
         Other

  Ages served x 0-3 yrs        x 3-5 yrs     x 6-12 yrs    x 13-21 yrs         Adult      Older Adult

                 PRIMARY CONDITIONS FOR WHICH OCCUPATIONAL THERAPY IS ADMINISTERED
   x    Adjustment Disorder             x    CVA/Hemiplegia                            Lymphedema
   x    Affective Disorder              x    Degenerative Neuro Disorder               Mental Retardation
        Alzheimer’s Disease             x    Developmental Disability            x     Neuromuscular Disorders
   x    Amputation                           Dementia                            x     Neonatology (NICU)
        Anxiety Disorder                     Diabetes                            x     Oncology
        Arthritis                       x    Dysphagia/Feeding Disorders               Personality Disorder
   x    Autism/PDD                           Eating Disorders                    x     Respiratory Disease
        Back Injury                     x    Eating/Feeding Problems                   Schizophrenic Disorder
   x    Burns                           x    Fractures & Gen Orthopedics         x     Spinal Cord Injury
   x    Cardiac Dysfunction             x    Hand/Wrist Disorders                      Substance Abuse
   x    Cerebral Palsy                       Hearing Impairment                  x     Traumatic Brain Injury
        Chronic Pain                         HIV/AIDS                            x     Visual Impairment
   x    Congenital Anomalies                 Learning Disorder                         Well Population
                                                                                       Other
ASSESSMENTS AND INTERVENTIONS
   I.    ASSESSMENTS

   Please see attached.




   II. INTERVENTIONS

   Role of OT in the Fieldwork Setting           x Direct                    Indirect

   Describe Intervention Hands-on handling, group treatment sessions (on rehab), clinic evaluations and follow-up




THEORETICAL MODEL(S) GUIDING PRACTICE
   Developmental Framework
   Biomechanical Framework
   Sensory Processing Approach

SPECIFIC DRESS CODE
   WOMEN                                                      MEN
   CONSERVATIVE CLOTHING IN GOOD REPAIR AND CLEAN             CONSERVATIVE CLOTHING IN GOOD REPAIR AND CLEAN
   FULL SHOES WITH SOCKS OR HOSE                              FULL SHOES WITH SOCKS
   NO VISIBLE LABELS                                          NO VISIBLE LABELS
   NO CLEAVAGE       PIERCINGS LIMITED TO EARS (1-2)          PIERCINGS LIMITED TO EARS (1-2)


PREREQUISITES:      THIS INFORMATION IS REQUIRED FOR BOTH LEVEL II AND LEVEL I STUDENTS (EXCLUDING
INTERVIEW)
        AIDS Certification          x Interview (indicate type)              x Pediatric CPR
   x Car Required **                     x In person (preferred)             x Physical Exam
   x Child Abuse Clearance               x Telephone (> 150 m distance)      x Prior Fieldwork Experience (indicate type)
   x CPR                            x Immunizations (check all that apply)      Must have completed first Level II
   x Criminal Background Check           x TB (PPD)                          X Proof of Health Insurance
        Drug Testing                     x Hep B                             x Tetanus
        Fingerprinting                   x MMR                               x Universal Precautions (OSHA)
   x HIPAA                               x Chicken Pox                            Other (please list)
                                            Other
                                    x Malpractice Insurance

** W E ARE UNABLE TO GUARANTEE THAT STUDENTS WILL BE PLACED AT THE MAIN HOSPITAL.         TRAVEL MAY BE REQUIRED TO OUR
SPECIALTY CARE CENTERS IN WHICH PUBLIC TRANSPORATION OPTIONS ARE LIMITED .
STUDENT INFORMATION


   Room Provided                        Access to Public Transportation        Meals
      On Grounds                        (specify)                                Breakfast       Lunch      Dinner
      Off Grounds                       SEPTA trains and buses                   Free            At cost x Purchase
   x No Room Provided                   www.septa.com
   Housing Available                    Stipend                                Hours
      Limited                              $       /Hr.                                            Weekdays
      Free                                 $       /Mo.                                            Evenings
      Student Pays $            /Mo.       $       /Session                                        Weekends
   x No Housing Available                  x No Stipend                        x                   Variable

   Other, please list




DATES

    Use AOTA suggested dates: strongly prefere            Use own dates


STUDENT SUPERVISION
Check all that apply:

x 1:1 Model
   Multiple students : one supervisor
x Multiple supervisors : one student

                                                                  Low                             High
Structure provided to students                                    1        2           3     4       5
(objectives, week-to-week guidelines)


                                                                  Low                             High
Nature of Supervision                                             1        2           3     4       5




Ending Student Expectation/Productivity                       30-36 in outpatient - # of clients per week
                                                              4-5 twice daily in rehabilitation - # of clients per day
                                                              75% - % productivity expectation
                                    OCCUPATIONAL THERAPY STAFF PROFILE
                                      (Check ( ) those who supervise OT fieldwork students)

SUPERVISES OT                                                            DEGREE AND           YEARS
 FIELDWORK
  STUDENTS                   NAME                        TITLE        COLLEGE/UNIVERSITY      IN OT      OT SPECIALTY
                Please see attached




COMMENTS (e.g., the general environment of your clinical site)

Please note: Should a student require medical assistance for an injury that occurs during the course of their internship
while involved in patient care at hospital, per school / facility contract Responsibilities of Seashore House - Section 8:

Responsibilities of Seashore House - Section 8:

"Seashore House will assist students in obtaining, from an appropriate local provider emergency medical care
required in the case of illness or injury during the affiliation. Students may be required to show proof of medical
insurance to the emergency care provider. Students are solely responsible for the cost of emergency medical care and
shall otherwise be responsible for obtaining and paying for their own medical care and health insurance, none of
which will be provided by Seashore House."

Please have your student identify a medical resource prior to beginning an internship at CHOP / Children’s Seashore
House.