AOTA FIELDWORK DATA FORM Date: Name of Facility: Address: City: State: Zip Code: FW Level II FW Level I (if different) Contact Person: Credentials: Contact Person: Credentials: Phone: E-mail: Phone: E-mail: Director: Corporate Status: For Profit Non-Profit State Gov’t Federal Gov’t Preferred Sequence of FW: Standards B.10.6 Any Second/Third only; 1st must be in: Full-time only Part-time option Prefer Full-time Phone: Fax: Web site address: OT Fieldwork Practice Settings (ACOTE Form A #s noted): (Click on boxes to check) settings Community-based settings School-based settings Age Groups: Number of In-Patient Acute 1.1 In-Patient Rehab 1.2 SNF/ Sub-Acute/ Acute Long-Term Care 1.3 General Rehab Outpatient 1.4 Outpatient Hands 1.5 Pediatric Hospital/Unit 1.6 Peds Hospital Outpatient 1.7 In-Patient Psych 1.8 Peds Community 2.1 Behavioral Health Community 2.2 Older Adult Community Living 2.3 Older Adult Day Program 2.4 Outpatient/hand private practice 2.5 Adult Day Program for DD 2.6 Home Health 2.7 Peds Outpatient Clinic 2.8 Early Intervention 3.1 School 3.2 area(s) please specify: 0-5 6-12 13-21 22-64 65+ OTRs: Aides: PT: Speech: Resource Teacher: Other: Student Requirements/Prerequisites (Check all that apply): (Click on boxes to check) ACOTE C.1.2 Health requirements: CPR type required: Medicare / Medicaid Fraud Check Criminal Background Check Protection/abuse check Adult abuse check Fingerprinting First Aid Infection Control training HIPAA Training Prof. Liability Ins. Own transportation Interview HepB MMR Tetanus Chest x-ray Drug screening # 10 Panel TB/Mantoux Physical Check up Varicella Influenza Please list any requirements:
Aspects of Occupational Therapy’s Domain addressed in this setting (Check all that apply): on boxes to check) *Refer to the OT Practice Framework –III (2014) for descriptions and definitions, AOTA.org Areas of Occupation Activities of Daily Living (ADL) Instrumental ADL Rest and Education Work Play Leisure Social Participation Client Factors Values, Beliefs and Spirituality Body Functions Body Structures Performance Skills Motor Skills Process Skills Social Interaction Skills Performance Patterns Habits Routines Rituals Contexts Cultural Personal Temporal Virtual Environments Physical Social Most common services priorities all that apply): (Click on boxes to check) Direct service Discharge planning Evaluation Meetings(team, department, family) Client education Intervention Consultation In-service training Billing Documentation of OT Interventions addressed in this setting (check all that apply): * ACOTE Standards A.5.3, C.1.1, C.1.3, C.1.8, C.1.10, C.1.12, C.1.16, and C.1.17 Areas of Occupation addressed in this setting - within client’s own environmental context (check all that apply): (Click on boxes to check) Activities of Daily Living (ADL) Instrumental Activities of Daily Living (IADL) Education Bathing/showering Bowel and bladder mgmt Dressing Eating Feeding Functional mobility Personal device care Personal hygiene & grooming Sexual activity Toilet hygiene Rest and Sleep Rest Sleep preparation Sleep participation Care of others (selecting/supervising caregivers) Care of pets Child rearing Communication management Community mobility Financial management Health management & maintenance Home establishment & management Meal preparation & up Religious observance Safety procedures & emergency maintenance Shopping Formal education participation Informal personal educational needs or interests exploration Informal personal education participation Work Employment interests & pursuits Employment seeking and acquisition Job performance Retirement preparation & adjustment Volunteer exploration / participation Social Participation Community
Play Play exploration Play participation Leisure Leisure exploration Leisure participation Family Peer/friend Types of Occupational Therapy Interventions: (Click on boxes to check) Occupations and Activities – client engages in occupations that match identified goals Purposeful Activity- activities add meaning, relevance, and are at the client’s level of interest and motivation Preparatory Methods and – practitioner selects directed methods and tasks that prepare the client for occupational performance. Group Interventions– using distinct knowledge leadership techniques to facilitate learning and skill acquisition across the lifespan through the dynamics of group and social interaction Education and Training – imparting knowledge and information about occupation, health, well-being and participation. Facilitate the acquisition of concrete skills for real-life goals Advocacy – efforts directed toward promoting occupational justice and empowering clients to seek and obtain resources to fully participate in their daily life occupations Method of Intervention Direct Services/case load for OT One-to-one: Small group(s): group: Discharge Outcomes of clients Home Another medical facility Home Health OT Intervention Approaches Create, promote (health promotion) Establish, restore, (remediation, restoration) Maintain Modify (compensation, adaptation) Prevent (disability prevention) Outcomes of Intervention Occupational performance Prevention Quality of Life Participation Role Competence Well-Being Occupational Justice Theory/ Frames of Reference/ Models of Practice Biomechanical Cognitive - Behavioral Cognitive Disability Model of Human Occupation (MOHO) Occupational Adaptation Person/ Environment/ Occupation (P-E-O) Person-Environment-Occupational Performance (PEOP) Rehabilitation Sensory Integration Social Learning Theory Stages of change / Transtheoretical Model Other (please list): Please list most common screenings and evaluations used in your setting: