AOTA FIELDWORK DATA FORM

Introduction:

The primary purpose of the Fieldwork Data Form is to summarize information regarding the program at a

fieldwork site. Occupational therapy (OT) and occupational therapy assistant (OTA) students will find valuable

information describing the characteristics of the fieldwork setting; the client population; commonly used

assessments; interventions; and expectations and opportunities for students. The Fieldwork Data Form has been

developed to reflect the Occupational Therapy Practice Framework: Domain and Process, 3rd Edition

(American Occupational Therapy Association [AOTA], 2014) terminology and best practice in occupational

therapy to promote quality fieldwork experiences. The data gathering processes used in completion of this form

entails a collaborative effort that facilitates communication between OT and OTA academic programs, students,

and fieldwork educators. This form may be completed by the combined efforts of the fieldwork educator, the

OT or OTA student assigned to the site for fieldwork, and/or the Academic Fieldwork Coordinator (AFWC)

from the program. Fieldwork sites are encouraged to update the form annually and provide a copy to the

educational program(s) where they have a current memorandum of understanding (MOU).

The secondary purpose of the Fieldwork Data Form is to document the connection between the curriculum

design of a given OT or OTA educational program with its fieldwork component. The AFWC will use the data

entered on the form to document fieldwork related Accreditation Council for Occupational Therapy (ACOTE)

Standards (ACOTE, 2012). The standards are outlined in Section C of the 2011 ACOTE standards and are

denoted on the form. Educational programs can revise the form to suit the needs of their respective fieldwork

programs.

The Fieldwork Data Form was developed through the joint efforts of the Commission on Education (COE) and

the Education Special Interest Section (EDSIS) Fieldwork Subsection with input from many dedicated AFWCs

and fieldwork educators.

AOTA FIELDWORK DATA FORM

Date: 3/2017Name of Facility: Mayo Clinic - St. Mary’s Hospital CampusAddress: Street: 200 1st St. SW City: Rochester State: MN Zip: 55905

FW I FW IIContact Person: Donna Heinle Credentials: OTD,

OTR/L, BCPRContact Person: Donna Heinle Credentials: OTD,

OTR/L, BCPRPhone: 507-255-7949 Email: heinle.donna@mayo.edu Phone: 507-255-7949 Email: heinle.donna@mayo.edu

Director: Donna Heinle Initiation Source: FW Office FW Site Student

Corporate Status: For Profit Nonprofit State Gov’t Federal Gov’t

Preferred Sequence of FW: ACOTE Standards B.10.6

Any Second/Third only; First must be in:       Full-time only Part-time option Prefer full-time

Phone: 507-255-7949Fax: 507-284-3431Website address: http://mayoweb.mayo.edu/mshs/

OT Fieldwork Practice Settings:Hospital-based settings Community-based settings School-based settings Age

Groups:Number of Staff:

Inpatient Acute Inpatient Rehab SNF/Sub-Acute/Acute Long-

Term Care General Rehab Outpatient Outpatient Hands Pediatric Hospital/Unit Pediatric Hospital Outpatient Inpatient Psychiatric

Pediatric Community Behavioral Health Community Older Adult Community Living Older Adult Day Program Outpatient/hand private practice Adult Day Program for DD Home Health Pediatric Outpatient Clinic

Early Intervention School

Other area(s)Please specify:     

0–5 6–12 13–21 22–64 65+

OTRs: 80OTAs/COTAs: 12Aides: 4PT: 120PTAs:18Speech: 15Psychologist: 4Other: Recreational Therapists:2

Student Prerequisites (check all that apply)ACOTE Standard C.1.2 Health requirements: CPR Medicare/Medicaid fraud check Criminal background check

(Minnesota and National both required) Child 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 TB/Mantoux

(2 TB Skin Tests 1- within 15 months of start date and 1 within 3 months of start date)

Physical Check up Varicella Immunization or Positive

titer if you have had chicken pox Influenza

Please list any other requirements:1. Communicable Disease and

Immunization Record2. Current Medical Insurance

Card

Please list how students should prepare for a FW II placement such as doing readings, learning specific evaluations and interventions used in your setting: ACOTE Standards C.1.2, C.1.11

Students can begin to prepare for FW II placement by familiarizing oneself with the role of occupational therapy in acute care settings. I would also review commonly used cognitive assessments and screenings such as the MOCA and SLUMS. It would be very beneficial to review common diagnoses found within each area such as orthopedic, general medicine, and cardiac/pulmonary.

Student work schedule and outside study expected: 7:00-4:00+

Other Describe level of structure for student?

Describe level of supervisory support for student?

Schedule hrs/week/day: 40-50 hrs/week Room provided yes no High High

Do students work weekends? yes no Meals yes no Moderate Moderate

Do students work evenings? yes no Stipend amount: N/A Low Low

Describe the FW environment/atmosphere for student learning:The fieldwork education model is a collaborative model that includes 1 clinical education coordinator/fieldwork educator to 3 OTS. This model promotoes collaborative learning, development from a high level of supervision to entry level independence, includes multiple approaches to learning such as traditional lecture based presentations, inservices, journal clubs (with OT, PT and RT students), peer feedback, case study and review, co-treatments, and OT theories and philosophies. The clinical education

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coordinator is a full time educator who provides continuous educational support through the mentoring throughout the fieldwork. In the absence of the clinical education coordinator, there are trained OT's on staff who are able to assume this position. Describe available public transportation:There is a good public transportation system called Mayo Park-n-Ride along with other local busing systems and multiple routes, free bus passes are offered in the town of Rochester to students. Check this link out: http://www.mayo.edu/mshs/campus-life/minnesota/transportation-and-parking

Types of OT interventions addressed in this setting (check all that apply): Occupations: Client-directed occupations that match and support identified participation level goals (check all that apply):ACOTE Standards C.1.8, C.1.11, C.1.12

Activities of Daily Living (ADL) Instrumental Activities of Daily Living (IADL) Education Bathing/showering Toileting and toilet hygiene Dressing Swallowing/eating Feeding Functional mobility Personal device care Personal hygiene and grooming Sexual activity

Rest and Sleep Rest Sleep preparation Sleep participation

Care of others/pets Care of pets Child rearing Communication management Driving and community mobility Financial management Health management and maintenance Home establishment and management Meal preparation and clean up Religious / spiritual activities and expression Safety and emergency maintenance Shopping

Formal education participation Informal personal education needs or interests exploration

Informal personal education participation

Work Employment interests and pursuits Employment seeking and acquisition Job performance Retirement preparation and adjustment Volunteer exploration Volunteer participation

PlayLeisure Social Participation

Play exploration Play participation

Leisure exploration Leisure participation

Community Family Peer/friend

Activities: Designed and selected to support the development of skills, performance patterns, roles, habits, and routines that enhance occupational engagement

Practicing an activity Simulation of activity Role play

Examples: Handouts, Driving Simulator, Etc.

Preparatory Methods and Tasks: Methods, adaptations and techniques that prepare the client for occupational performance

Preparatory tasks Exercises Physical agent modalities Splinting Assistive technology Wheelchair mobility

Examples:      

Education: describe     

Training: describe      

Advocacy: describe     

Group Interventions: describe     

Method of Intervention

Direct Services/Caseload for entry-level OT

One-to-one:      Small group(s):      Large group:     

Discharge/Outcomes of Clients (% clients)

Home Another medical facility Home health

Outcomes of InterventionOccupational performance improvement and/or

enhancement Health and Wellness Prevention Quality of life Role competence Participation

OT Intervention Approaches Create, promote health/habits Establish, restore, remediate Maintain Modify, facilitate compensation, adaptation Prevent disability

Theory/Frames of Reference/Models of Practice Acquisitional Biomechanical Cognitive/Behavioral Coping Developmental Ecology of Human Performance Model of Human Occupation (MOHO) Occupational Adaptation Occupational Performance Person-Environment-Occupation (PEO) Person-Environment-Occupational Performance

(PEOP)Psychosocial Rehabilitation frames of referenceSensory IntegrationOther (please list): Gestalt

Please list the most common screenings and evaluations used in your setting:3

Cognitive Screens:-Brief Cognitive Status Exam (BCSE)-Kohlman Evaluation of Living Skills – 4-Executive Functional Performance Test (EFPT)-Short Blessed-St. Louis University Mental Status Exam (SLUMS)-Trailing Making-Montreal Cognitive Assessment (MOCA)-Allen Cognitive Level Screen- 5Standardized Evaluations:-Cognitive Performance Test/Home Assessment Cognitive Performance Test (CPT)-Cognitive Assessment of Minnesota (CAM)-Executive Function Performance Test (EFPT)-Canadian Occupational Performance Measure (COPM)-Independent Living Scales (ILS)-Texas Functional Living Scales (TLFS)-Nine Hole Peg-Dynamometer/Pinch Testing-Manual Muscle Test-Range of MotionNon-Standardized Evaluations:-Semi-Structured Interview-Mayo Functional Cognitive AssessmentIdentify safety precautions important at your FW site

Medications Postsurgical (list procedures) Contact guard for ambulation Fall risk Other (describe): Lab Values and Vitals

Swallowing/choking risks Behavioral system/ privilege level (locked areas, grounds) Sharps count1 to 1 safety/suicide precautions

Performance skills, patterns, contexts and client factors addressed in this setting (check all that apply): ACOTE Standard C. 1.12

Performance Skills:Motor skillsProcess skills Social interaction skills

Performance Patterns:Person:

Habits Routines Rituals Roles

Group or Population: Habits Routines Rituals Roles

Client Factors: Values Beliefs Spirituality Mental functions (affective, cognitive, perceptual) Sensory functions Neuromusculoskeletal and movement-related

functions Muscle functions Movement functions Cardiovascular, hematological, immunological, and

respiratory system functionsVoice and speech functions; digestive, metabolic, and

endocrine system functions; Skin and related-structure functions

Context(s): Cultural

Personal Temporal Virtual

Environment: Physical Social

Most common services priorities (check all that apply): Direct service Discharge planning Evaluation

Meetings (team, department, family) Client education Intervention

Consultation In-service training

Billing Documentation

Target caseload/productivity for fieldwork students: Documentation: Frequency/Format (briefly describe) :

Productivity ( %) per 40-hour work week: 60% billable time

Caseload expectation at end of FW: 7-9 patients per day

Productivity (%) per 8-hour day: 60% billable time

Number groups per day expected at end of FW: 0-1

Handwritten documentation:       Computerized medical records: MICS, Synthesis, Short Han, Hot List,

Evaluations and Treatment Template

Time frame requirements to complete documentation: 12-24 hours

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Administrative/Management Duties or Responsibilities of the OT/OTA Student:

Student Assignments. Students will be expected to successfully complete:

Schedule own clients Supervision of others (Level I students, aides, OTA, volunteers) Budgeting Procuring supplies (shopping for cooking groups, client/intervention-related items)

Participating in supply or environmental maintenance Other:      

Research/EBP/Literature review In-service Case study In-service participation/grand rounds Fieldwork project (describe): Journal Club Presentations, Cognitive

Review Assessment Review and Presentation-based on department and student needs

Field visits/rotations to other areas of service Observation of other units/disciplines Other assignments (please list): Individual Course Assignments

OPTIONAL DATA COLLECTION:

The question includes in this section may be used by academic programs to demonstrate compliance with the Accreditation Council for Occupational Therapy Education (ACOTE) Standards documentation for fieldwork.

1. Please identify any external review agencies that accredit / recognize this FW setting and year of accreditation/ recognition. Examples: JCAHO, CARF, Department of Health, etc.

Agency for External Review: Joint Commission JACHOYear of most recent review: June 2016Summary of outcomes of OT Department review: There were no issues cited for the OT Department.

Agency for External Review: (name)     Year of most recent review:      Summary of outcomes of OT Department review:      

Agency for External Review: (name)     Year of most recent review:      Summary of outcomes of OT Department review:      

2. Describe the fieldwork site agency stated mission or purpose (can be attached). Mission Statement: Physical Medicine and Rehabilitation will provide the best interdisciplinary rehabilitation care to each person served to enhance their functional ability and quality of life through integrated clinical practice, education, and research.

3. OT Curriculum Design Integrated with Fieldwork Site (insert key OT academic curricular themes here) ACOTE Standards C.1.2, C.1.3,C.1.7, C.1.8, C.1.11,C.1.12

a. How are occupation-based needs evaluated and addressed in your OT program?Occupation-based needs are evaluated based on the Occupational Therapy Practice Framework 3 rd Edition 2014.Mayo Clinic provides treatment areas that are occupation based such as access to the large therapeutic treatment environment and therapeutic apartment. During each evaluation, each patient is asked about their living environment, activities of daily living, instrumental activities of daily living, and leisure activities to aid the therapist in providing a client centered intervention plan to meet the patient’s needs and desires.

b. Describe how you seek to include client-centered OT practice. How do clients participate in goal setting and intervention activities?Through the initial evaluation and building an occupational profile, therapists seek to understand the patient’s needs and interests prior to injury/incident. Working together, the patient and therapist identify current barriers to daily living and identify appropriate goals and interventions to increase independence and prepare the client for his/her next stage of recovery.

c. Describe how psychosocial factors influence engagement in occupational therapy services. In a setting such as acute care, patients experience a wide variety of psychosocial factors. These factors are just as important to address in this setting as they may inhibit participation in therapy and hinder the recovery process. These factors are important for OT to address and collaborate with other members of the healthcare team and patients family/significant others.

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d. Describe how you address clients’ community-based needs in your setting.Occupational therapists address community-based needs by providing patients with adaptive equipment options for the patients to choose from. Therapists also provide different handouts including exercises and precautions. In collaboration with the patient, the patient’s family, social work and other team members, OT aids in discharge planning and their community-based needs, as well as referrals to other areas.

4. How do you incorporate evidence-based practice into interventions and decision making? Are FW students encouraged to provide evidence for their practice? ACOTE Standards C.1.3, C.1.11

Students will incorporate evidence-based practice into interventions and decision making by always asking themselves the “why” question and make sure they are able to support with clinical reasoning skills. Students will incorporate evidence-based practice by completing several assignments including the Journal Club and Cognitive Assessment Review Presentation. By incorporating evidence into practice, not only do students increase their knowledge base, but to communicate better and more knowledgably with patients, families and other healthcare providers.

5. Please describe the FW Program and how students fit into the program. Describe the progression of student supervision from novice to entry-level practitioner using direct supervision, co-treatment, and monitoring, as well as regular formal and informal supervisory meetings. Describe the fieldwork objectives, weekly fieldwork expectations, and record keeping of supervisory sessions conducted with student. Please mail a copy of the FW student objectives, weekly expectations for the Level II FW placement, dress code, and copy of an entry-level job description with essential job functions to the AFWC. ACOTE Standards C.1.1, C.1.2, C.1.3, C.1.4, C.1.8, C.1.9

This Level II Fieldwork experience is provided in an acute setting (1200 + bed hospital). Students begin on a trauma orthopedic unit and intensive care units. The students begins here as there is 1:1 direct supervision for the intensive care unit patients and the orthopedic unit offers traditional / basic OT with adaptive equipment training and protocols following procedures. Then, the students transition to the General Medicine/Internal Medicine units. On these units, the students challenge their clinical reasoning abilities as the OTS begins to diagnosis function, applied cognition, and make predictions/recommendations for safe dismissal planning. On the General Medicine/ Internal Medicine units, the students are beginning to prioritize care and addressing what will most impact the patient right now. Finally, the student team rotates to the cardiac/pulmonary units where life skills are reinforced and OT's role may be one of life coach. At this juncture, the students also revisit the intensive care units. By week 10, the students are almost functioning at an entry-level. Weekly team meetings are offered and weekly individual meetings are mandatory. During the individual meetings, the fieldwork educator meets with each student and establishes personal goals for the up-coming week.

Six weeks before beginning your fieldwork the Mayo School of Health Sciences will contact you and ask for the following information. This all must be on file no less the one month prior to your start date.

Communicable Disease and Immunization form (MSHS provides) Copy of your immunization record to include 3 hepatitis B vaccines, 2 MMR vaccines,

and either 2 varicella vaccines or a positive varicella titer if you’ve had the disease in the past.

Documentation of a flu shot Documentation of two TB tests, one within the past 15 months and one within the past 3

months Proof of insurance card Background checks (both Minnesota and National)  

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YOUR FIRST DAY-WHAT TO EXPECT

**Please report to the Seibens Building – 11th Floor, Room 32 200 1st St. SW, at 8:00 a.m. on the first day of your clinical experience. ** (Go to: http://www.mayoclinic.org/mcitems/mc1600-mc1699/mc1663-14.pdf for a detailed map of the downtown campus and the exact location of the Seibens building). Mayo School of Health Sciences Student Services Department will be providing all of the institutional orientation requirements for your internship at Mayo. A PM&R employee will meet after this orientation session and continue with more Mayo orientation, PM&R department-specific orientation and a tour of the Mayo campus facilities.

DISABILITY SERVICES POLICY

Successful accommodation of a student’s needs takes time and careful planning. The student must request accommodations for a disability as soon as possible. For a new matriculating student, this should be done at least 6 weeks before arrival for orientation. Full policies and procedures are available upon request or able to view on the internal Mayo School of Health Sciences webpage upon arrival to Mayo Clinic.

DRESS CODE

In Physical Medicine and Rehabilitation (PM&R), all staff and students are required to dress in “business casual” attire. Staff and students do not wear scrubs in any of the PM&R work units. Please review the information sent to you at the time of formal confirmation.

HOUSING OPTIONS

A list of options will be provided to students once their internship is confirmed.

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OT STUDENT FIELDWORK OBJECTIVES

FUNDAMENTALS OF PRACTICE

1. Adheres consistently to the American Occupational Therapy code of ethics and sites policies and procedures including when relevant, those related to human subjects research:

Demonstrates a concern for the wellbeing of the clients of their services. Fulfills professional obligation of acting out of beneficence in dealing with all clients.   Takes

reasonable precautions to prevent imposing or inflicting harm upon the client of their services or to his/her property.

Respects the client or his/her surrogates, as well as the client’s rights (autonomy, privacy, and confidentiality).

Achieves and maintains high standards of competence (duties). Takes the initiative to complete all assignments and responsibilities to provide the best client care. Complies with laws and student policies guiding the profession of occupational therapy as stated in the

AOTA code of ethics (2005) and Mayo policies and procedures. Treats colleagues and other professionals with fairness, discretion and integrity.  Maintains client privacy, confidentiality and security of medical record information observing federal,

state and facility regulations.  Information cannot be shared verbally, electronically, or in writing without the appropriate consent.  Information must be shared on a need-to-know basis only with those having primary responsibilities for decision making. 

Seeks out the clinical instructor if there are any questions regarding conflict of interest as it is imperative to maintaining the integrity of interactions. 

Will not have any personal or sexual relationships that occur during any professional interaction, as it is a form of misconduct.

If a student is considered to be impaired, he/she will volunteer to terminate his/her fieldwork experience if he/she is not able to competently perform his/her duties after given reasonable accommodations.

2. Adheres consistently to safety regulations, anticipates potentially hazardous situations and takes steps to prevent accidents:

Follows universal precautions and hospital safety policies for all clients. Review chart and/or seek to understand information from appropriate sources, i.e. asks questions when

needed for clarification.

3. Uses judgment in safety.  Uses sound judgment in regard to safety of self and others during all fieldwork related activities:

Awareness of, will identify, and will follow through with precautions and contraindications to carry out a client’s plan of care.

Justify the use of selected activities within the limits of established precautions and lab values/vitals in relation to safety with function.

Make appropriate decisions regarding the need for assistance during evaluation and treatment sessions. Maintain the work area and supplies that are conducive to safety. Understand and be able to manage the lines and equipment in the Intensive care unit.

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BASIC TENETS

1. Articulates the values and beliefs of the OT profession: Explains the rationale for client’s care plan related to occupational therapy intervention. Demonstrates an awareness of when it is appropriate to initiate contact with the above people to

articulate the role of OT related to a client’s care. Adjusts terminology according to the audience addressed. 

2. Articulates the value of occupation: Consistently communicates how treatment activities and care plan will affect occupational performance

and outcomes for clients and medical professionals.

3. Communicates the roles of occupational therapist and occupational therapy assistant: Clearly recognizes and can verbalize the role delineation between the OT and the COTA.

4. Collaborates with client, family and significant others throughout the occupational therapy process:

Consistently involves the client, family and/or significant others in the goal setting process.  Makes appropriate decisions regarding sharing information with the above people.  Provide professional, timely, objective and clear consultation with all health care providers, vendors,

school systems, etc.

EVALUATION AND SCREENING

1. Articulates a clear and logical rationale for the evaluation process: Understands the theoretical basis or frame of reference for administered evaluations. Identifies appropriate options for assessments for specific client situations. 

2. Selects relevant screening and assessment methods while considering such factors as client’s priorities, context(s), theories, and evidence-based practice: 

Demonstrates the ability to select and prioritize relevant areas to assess. Seek out the assistance of staff and other resources when in doubt about accurate administration. Make appropriate decisions regarding when to utilize standardized vs. non standardized assessments.

3. Determines the client’s occupational profile and performance through appropriate assessment methods:

Demonstrates the ability to gather appropriate information, including a thorough interview, from the client, family, significant others, medical staff and medical records. 

4. Assess client factors and context(s) that support or hinder occupational performance: Reviews the medical history and precautions prior to assessing the client.

5. Obtains sufficient and necessary information from relevant resources: Select and filter pertinent information to provide ethical and quality client care.

6. Administers assessments in a uniform manner to ensure that findings are valid and reliable: Assessment tools Screening tools

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7. Adjusts/modifies the assessment procedures based on client’s needs, behaviors and culture: Demonstrates and rationales using critical thinking and flexibility in adapting assessments to meet the

client’s individual needs.

8. Interprets evaluation results to determine client’s occupational performance strengths and challenges:

Utilize evaluation results to determine client’s limitations and strengths to assist in reaching the best possible outcomes.

9. Establishes an accurate and appropriate plan based on evaluation results: Identifies the appropriate time to re-evaluate the client’s program and documents the re-assessment

information.  Establishes relevant and attainable short and long-term goals that reflect the assessment data and the

occupational performance of the client and his/her individual and family goals. Evaluate a client’s functional status and make the optimal clinical judgment to decide if a client can

function safely at home or the type of supervision that is warranted. Appreciates the importance of having a goal-directed plan.

10. Documents the results of the evaluations: Records the results of assessments accurately, concisely, and selects relevant information to report and

document.

INTERVENTION

1. Articulates a clear and logical rationale for the intervention: Uses clinical reasoning to explain clients, fieldwork educator, and medical professionals the rationale for

the OT intervention and plan of care.

2. Utilizes evidence from published research and relevant resources to make informed decisions: Utilize multiple resources to provide rationale and support for treatment plans (EBM, EBP). Access and utilize the AOTA’s Evidence based practice web site for evidence based practice during this

affiliation.

3. Chooses occupations that motivate and challenge clients: Obtain an occupational profile to direct intervention that facilitates the “just right challenge” for the

clients to optimize functional independence. Recognize and adapt to therapeutic age and therapeutic moments in client care.

4. Selects relevant occupations to facilitate clients meeting established goals: Able to break a given occupation into a sequence of steps according to the client’s level of functioning

and cognitive abilities.  Demonstrates creativity and flexibility in choosing treatment activities.  Works to expand own repertoire of known activities. Seeks out new activities from the staff and other available resources.

5. Implements intervention plans that are client centered: Makes appropriate decisions regarding reviewing progress with client throughout the intervention

process.

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Consistently communicates treatment program, updates and dismissal plans to the client and/or their families/significant others.

6. Implements intervention plans that are occupation based: Consistently seeks out and utilizes activities that are purposeful and meaningful for the client.

7. Modifies task approach, occupations and the environment to maximize the client’s performance: Understands the concepts of “graded” activity. Determines logical sequence of treatment activities to attain the established goals.  Chooses and modifies the environment appropriate for the client’s needs. Demonstrates flexibility and resourcefulness in adapting the treatment activities, area and care plan as

the client’s needs change. 

8. Updates, modifies or terminates the intervention plan based upon careful monitoring of the client’s status: 

Understands and revises goals in an appropriate and realistic manner. Appreciates the need for client involvement in goal modification. Coordinates discharge planning with other disciplines so that continuity of care exists. Consistently has adaptive equipment and home environmental recommendations in place prior to client

dismissal. Awareness of options for resources that are available to clients upon dismissal.  Demonstrates an awareness of when to discontinue treatment and the ethical implications of client

dismissal from OT services.

9. Documents client’s response to serve in a manner that demonstrates the efficacy of interventions: Complete daily and weekly documentation in a timely manner and utilize skilled terminology for

documentation.

MANAGEMENT OF OT SERVICES

1. Demonstrates through practice or discussion the ability to assign appropriate responsibilities to the COTA or the OT aid:

Demonstrate leadership and mentoring of support staff. Be respectful in all communication and professional dialogue with all staff.

2. Demonstrates through practice or discussion the ability to actively collaborate with a COTA: Collaborate with COTA to write appropriate treatment plan and goals for clients. Verbalize an awareness of the role of the OT in the facilitation of COTA competencies.

3. Demonstrates an understanding of the costs and funding related to OT services at this site: Verbalize understanding of DRGs, PPS system, insurance premiums, co-pay, private funding, govt.

funding PPS, FIM, CPT codes, ICD-9 codes. Will have working knowledge of CPT codes.4. Accomplishes organizational goals by establishing priorities, developing strategies and meeting

deadlines: Consistently meets deadlines assigned by fieldwork educator. Adjust pace and prioritize daily responsibilities.

5. Produces the volume of work required in the expected time frame: Manage a caseload and meet productivity expectations outlined by the department, i.e. 60% billable

time.11

Calculate the amount of time needed to complete a task and use time outside of the clinic for task completion as needed.

COMMUNICATION

1. Clearly and effectively communicates verbally and nonverbally with clients, families, significant others, colleagues, service providers, and the public:

Provides the above with professional and self-confident, honest and verbal feedback regarding the results of assessments, treatment interventions and goal status. 

Is able to discern which families may need additional instruction and demonstration; provides this information in a way that is not demeaning to the family. 

Listen attentively to what is being said by others and integrate this information into the treatment plan immediately.

Deliver an articulate message verbally, via phone or e-mail and in written form. Identify and build strategies to handle critical and crucial conversations with family members and

clients.

2. Produces clear and accurate documentation according to site requirements: Selects relevant information to report and document. Completes all assigned daily documentation. Creates written, electronic and verbal reports that accurately reflect the client’s status.

3. All written communication is legible using proper spelling, punctuation, and grammar: Provides accurate information about OT services in written, electronic and verbal communication.  The

OT student will always provide accurate documentation in any client care record. 

4. Uses language appropriate to the client of the information, including but not limited to funding agencies and regulatory agencies:

Adjusts terminology according to the audience addressed.   Will not use abbreviations according to department/institution policy. 

PROFESSIONAL BEHAVIORS

1. Collaborates with supervisors to maximize learning experience: Accepts responsibility for initiating and communicating desires/optimal learning experiences with

fieldwork educator. Be self-directed in determining learning strengths and challenges.

2. Takes responsibility for obtaining professional competence: Demonstrates clinical reasoning, critical thinking, and self-reflection on a daily basis. Appreciates the balance between independent problem solving and seeking out assistance from others.  Independently seeks experiences and information to supplement learning and professional growth. 

3. Responds constructively to feedback: Accepts feedback from the fieldwork educator in a non-defensive manner and adjusts professional

behaviors accordingly.

4. Demonstrates consistent work behaviors:

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Arrive on time and consistently is prepared to start the day upon arrival. Complies with Mayo Dress Code Policies.

5. Demonstrates effective time management: Organizes schedule to allow for the timely completion of assignments and client related duties. 

6. Demonstrates positive interpersonal skills: Demonstrates mutual respect for all individuals in the work environment.  Develop and maintain a rapport with clients that enhances the therapeutic relationship.

7. Demonstrates respect for diversity: Considers cultural and economic background when establishing goals and care plans. Deals effectively with a variety of disabilities, age groups, socioeconomic and cultural backgrounds. Respects diversity in the work place.

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PM&R ACUTE CARE: WEEKLY OUTLINE/GOALS

WEEK 1___ Student will meet with Donna Heinle, OTD, OTR/L, BCPR - CCCE___ Student will get photo ID taken for Mayo badge___ Student will attend orientation sessions, review over Mayo policies/procedures, and complete institution competencies as outlined by clinical education coordinator (CEC) /fieldwork educator and CCCE.___ Student will collaborate with CEC to discuss and assign department and school

assignments and projects (discipline lunch & learn topics, final group projects, cognitive assessment education, etc).

___ Student will review student manual contents and comprehend included information. Student is expected to refer to and utilize manual or electronic resource (Dropbox) as a reference throughout the internship.

___ Student will demonstrate competency in use of pager, telephone systems, and e-mail.___ Student will become familiar with electronic documentation and billing protocol.___ Student will identify and recognize with signing up for patients on PMRCO list through electronic medical record.___ Student will participate in education specific to hospital room equipment (bed, call light, lift system, bathroom set-up, linen carts, Par-Stock, lap tray).___ Student will complete be familiar with functional mobility transfer techniques (bed, sit-to-stand, toilet transfer).___ Student will shadow assigned staff therapist when they are not participating in direct

patient care.___ Student will review Mayo Clinic patient handouts specific to safety folder.___ Student will review Mayo Clinic patient handouts specific to orthopedic diagnoses.___ Student will individually perform chart/history review, evaluation, intervention,

document with assigned patient(s) with direct supervision of clinical education coordinator (CEC)/fieldwork educator.

___ Student will collaborate with other students while intervening with patients, i.e. chart/history review, evaluation, intervention, document. CEC will assign patients to student team.

___ Student will collaborate with team and CEC to observe and document a patient evaluation and/or treatment session using fieldwork site documentation and billing system.

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WEEK 2___ Student will meet with clinical education coordinator 1:1 to discuss progress and individual goals.___ Student will identify a system to organize and maintain patient workload while

recalling safety precautions, etc. (i.e. index card per patient, clipboard, etc.). ___ Student will create and start using an evaluation and/or treatment document form to organize and support patient information for documentation.

___ Student will bill correctly and ethically for patient evaluations/interventions with moderate assistance from CEC.

___ Student will be familiar with department equipment, activities, and evaluations that are available to them.

___ Student will demonstrate the ability to safely transfer their patients from one surface to another and/or will be able to recognize when additional assistance is needed.

___ Student will be familiar with cognitive screens used at fieldwork site (Short Blessed Test, SLUMS, Trails Making, MoCA versions)___ Student will complete self-assessment sheet and will complete them

PRIOR to next week’s 1:1 meeting with clinical education coordinator (CEC).  ___ One student out of group will participate in nursing/social worker patient rounds.

___ CASELOAD MANAGED:  Student will individually manage chart/history review, evaluation, intervention,

documentation with 1-3 patients per day (Billable Goal 2-3) with direct supervision to moderate supervision of the CEC/fieldwork educator.  Student will be assigned to patients via CEC/fieldwork educator.

WEEK 3___ Student will meet with clinical education coordinator 1:1 to discuss progress and individual goals.___ Student will be assigned to patients via CEC/fieldwork educator; approximately two-

three hours of direct patient care per day.___ One student will complete literature review/evidence on an general medicine topic related to patient. The student will provide a presentation on this topic to fellow OT staff and interns

during a lunch hour meeting.  Each student is responsible to read the information and come prepared for discussion at the group meeting___ One student out of group will participate in nursing/social worker patient rounds. ___ Student will start learning the procedure, scoring, and interpretation of their assigned cognitive assessments (CPT, ACLs-5, AM-PAC, TFLS, ILS,EFPT). The goal is to be familiar with the cognitive assessment to be able to educate the fellow student peers within the next week.

___ CASELOAD MANAGED: Student will individually manage chart/history review, evaluation, intervention, documentation with 2-4 patients per day (Billable Goal 2-4); with

moderate to minimal supervision of CEC/fieldwork educator. 

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WEEK 4___ Student will meet with the CEC/fieldwork educator 1:1 to discuss progress and

individual goals as needed.___ Student will be independent with signing up and managing patient’s on assigned area

of PMRCO patient list.___ One student out of group will participate in nursing/social worker patient rounds. ___ Student will be familiar with and begin practicing department safety evaluations that are available to them and as opportunities arise with patient care.___ Student will receive information via CEC/fieldwork educator and will read

information and begin to prepare for transition to Gen Med unit next week. At the end of the week, students will be able to discuss and verbalize understanding of transition and expectations.

___ Student will complete General Medicine floors tour with CEC and be able to identify intervention tool/supplies on each floor

___ CASELOAD MANAGED: Student will individually manage chart/history review, evaluation, intervention, document with 3-5 patients per day (Billable Goal 3-5) with minimal to indirect

supervision of CEC/fieldwork educator. 

WEEK 5___ Student will transition to General Medicine floors (Domitilla)___ Student will continue to practice demonstrating their ability to facilitate

department safety evaluations using the following: cognitive assessments/screen, upper extremity evaluation, including ROM and manual muscle testing, ADL evaluation, adaptive equipment, home & safety evaluation by mid-term as opportunities present with patient care.

___ Student will collaborate with a COTA and develop a partnership (OT/OTA) while on the General Medicine floors as possible.  Students will assign patients to COTA and work respectfully in an OTS/COTA partnership as opportunities arise with COTA.

___ CASELOAD MANAGED: Student will individually manage chart/history review, evaluation, intervention,

document with 3-5 patients per day (Billable Goal of 4) with minimal supervision to indirect supervision of CEC/fieldwork educator.  Students will assign patients to self from work-

list independently; approximately four hours of direct patient care per day.

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WEEK 6___ Student will meet with CEC 1:1 to complete mid-term self-assessment using AOTA fieldwork evaluation. AOTA evaluation will be 1:1 with CEC. Identify goals for the second half of fieldwork experience as well as interest areas for observation. ___ Student will collaborate with a COTA for coverage on General Medicine floors

Students will assign patients to COTA and work respectfully in an OTS/COTA partnership as opportunities arise with COTA.

___ Student will be able to demonstrate the ability to facilitate department safety evaluation the following: CPT, ACL-5, EFPT, TFLS, ILS, AM-PAC, and upper extremity evaluation, including ROM and manual muscle testing, ADL evaluation, adaptive equipment, home & safety evaluation. 

___ CASELOAD MANAGED: Student will individually manage chart/history review, evaluation, intervention, document with 4-6 patients per day (Billable Goal 5) with indirect supervision of CEC/fieldwork educator. Students will assign patients to self from work-list

Independently.

WEEK 7___ Students will begin to rationalize caseload and divide up PMRCO caseload as a team without the assistance of the CEC___ Student will have observed in at least one area of interest with another discipline, i.e.

physical therapy session, speech therapy session, surgical procedure, etc.___ Student will be familiar with and begin practicing department safety evaluations that are available to them and as opportunities arise with patient care. ___One student will complete literature review/evidence on a general medicine topic related to patient. The student will provide a presentation on this topic to fellow OT staff and interns

during a lunch hour meeting.  Each student is responsible to read the information and come prepared for discussion at the group meeting.

___ CASELOAD MANAGED: Student will individually manage chart/history review, evaluation, intervention, document with 4-6 patients per day (Billable Goal 5-6) with indirect supervision of

CEC/fieldwork educator. Students will assign patients to self from work-list independently

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WEEK 8

___ Students will begin to rationalize PMRCO caseload and divide up unit caseload as a team without the assistance of the CEC___ Student will receive and are expected to read cardiac information in preparation for transition

to cardiac unit. Complete all competencies prior to transition to cardiac/pulmonary floors.___ Student will prepare for transition to cardiac/pulmonary floors next week. Tour of cardiac /

pulmonary floors with CEC will be completed.

___ CASELOAD MANAGED: Student will individually manage the chart/history review, evaluation, intervention, document of 5-7 patients per day (Billable Goal of 6) with supervision to indirect supervision of

CEC/fieldwork educator. Students will assign patients to self from work-list Independently.

WEEK 9 ___ Student will meet with clinical education coordinator 1:1 to discuss progress and individual goals at the end of the week to prepare for next week.___ Students will begin to rationalize PMRCO caseload and divide up unit caseload as a team without the assistance of the CEC___ Student will verbalize understanding of all cardiac/pulmonary precautions pertaining to

patient safety during OT evaluations/interventions.

___ CASELOAD MANAGED Student will individually manage 3-6 patients per day (Billable Goal of 4-5) with indirect supervision of CEC/fieldwork educator for patient on Progressive Care Units (PCU) and direct supervision/assistance for patients in Intensive Care Units (ICU) or Respiratory Care Unit (RCU).

WEEK 10___ Student will begin to rationalize PMRCO caseload and divide up unit caseload as a team without the assistance of the CEC___ Student will review Intensive Care Unit (ICU) manual as well as Left Ventricle Assist Device (LVAD) manual. Student will participate in education on LVAD with hands on experience

with device as opportunities arise. ___ Student will collaborate with fellow acute care therapist to work with patient implanted with

LVAD with direct supervision or observation.

___ CASELOAD MANAGED: Student will individually manage 5-7 patients per day (Billable Goal of 6) with indirect supervision of CEC/fieldwork for Progressive Care units (PCU) and 1:1 direct supervision

for patients in ICU or RCU. Students will assign patients to self from work-list independently.

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WEEK 11___ Student will meet with clinical education coordinator 1:1 to discuss progress and individual goals at the end of the week to prepare for next week as needed.___ Students will begin to rationalize PMRCO caseload and divide up caseload as a team without

the assistance of the CEC___ One student will complete literature review/evidence on a cardiac/pulmonary topic related to

patient care. The student will provide a presentation on this topic to fellow OT staff and interns during a lunch hour meeting.  Each student is responsible to read the information and come prepared for discussion at the group meeting.

___ Student will collaborate with fellow acute care therapist to work with patient implanted with LVAD with direct supervision or observation.

___ Student(s) will present final project to staff or students as assigned at the beginning of the fieldwork ___ Student will start planning for closure with his/her patients.

___ CASELOAD MANAGED:Student will individually manage 5-7 patients per day (Billable Goal of 6) with indirect supervision of CEC/fieldwork educator for patients on PCU and 1:1 direct supervision for

patients in ICU or RCU. Students will assign patients to self from work-list independently

WEEK 12___Students will begin to rationalize PMRCO caseload and divide up caseload as a team without

the assistance of the CEC___Student will complete final AOTA Evaluation with CEC___Student will provide feedback to Donna Heinle, OTD, OTR/L, BCPR - CCCE___Student will complete the AOTA Student Evaluation of Fieldwork Experience.

___ CASELOAD MANAGED: Student will individually manage 6-8 patients per day (Billable Goal of 6) with indirect supervision of CEC/fieldwork educator for patients on PCU and 1:1 direct supervision for

patients in ICU or RCU. Students will assign patients to self from work-list independently

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6. Please describe the background of supervisors by attaching a list of practitioners who are FW educators including their academic program, degree, years of experience since initial certification, and years of experience supervising students) ACOTE Standards C.1.9, C.1.14, C.1.17, C.1.19     

Name Hire Date Title Yrs of Practice College/University Degree Expertise

Amundson, Kelly M.

6/7/2004 OT 13 Concordia University, Mequon AAS, MS Hand

Anshus, Danielle

2/7/2017 OT University of Wisconsin-La Crosse MOT Neuro

Andersen, Renee J.

2/3/1992 OT 25 University of North Dakota BS OT, CHT Hand, Management

Arroyo, Hillery 11/1/2015 OT 14 Washington University MOT Hands, Neuro

Baczynski, Kim 9/8/2008 OT 10 College of St. Catherine MA OT Acute, Geriatric

Barreto, Stefano M.

3/3/2008 OT 10 Virginia Commonwealth University MS OT Brain Rehab, Spine Rehab, Acute, TBI, Dysphagia

Becker, Katie 5/4/15 OT 4 University of Wisconsin – LaCrosse MS, OTR/L Acute

Bergstrom, Jennifer

5/10/2010 OT 9 University of Wisconsin - LaCrosse MOT Dysphagia, Acute, Rehab

Bernard, Shari L.

1/2/1990 OT 30 Mount Mary College BS OT, SCFES, OTD

Oncology, Arthritis, Dysphagia Work, Geri, Acute, Management

Bodensteiner, Emily

9/21/2016 OT University of Minnesota MOT ICU

Brumfield, Kathy A.

1/3/1995 OT 23 University of North Dakota BS OT Peds

Butterfass, Ellen S.

10/21/2002 OT 24 College of St. Catherine BS OT Peds

Canny, Mark L. 8/31/1992 OT 25 College of St. Catherine MA OT Pain Rehab, Acute

Chhugani, Daksha

7/16/2012 OT 31 Seth G.S. Medical College, Mumbai India BS OT Rehab, Dysphagia, Geri, Acute, Ortho, Cancer Rehab

Christensen, Gina

11/10/2008 OT 26 College of St. Catherine MA OT BCPR Acute, Dysphagia, Pain Rehab

Chhugani, Daksha

7/16/12 OT 31 Seth G. S Medical College, Mumbai India BSOT Dysphagia, Geri, Acute, Ortho, Cancer

Clark, Mary B. 2/1/1999 OT 20 University of North Dakota BS OT Dysphagia, Hand, Geri, Acute, OP, Ortho, Cardiac

Coughlin, Donna K.

2/15/1999 COTA 32 Kirkwood Community College AS COTA Geri

Dahlhauser, Sarah

6/7/2010 OT 7 University of North Dakota/Creighton University MSOT Outpatient dysphasia, wheelchair, neurodegenerative diseases, general orthopedics

Demirsar, Julie M.

7/16/1990 OT 29 University of North Dakota BS OT Peds

Drath, Kimberly L.

11/12/2001 OT 28 College of St. Catherine BS OT Acute, Psych, Dysphagia

Dreiling, Nicole 7/11/2007 COTA 18 North Dakota State College of Science AS COTA Acute, Rehab, Brain & Spine

Edvenson, Julie R.

5/1/1995 OT 27 University of North Dakota BS OT OP, Dysphagia, Vestibular Rehab, Low Vision

Elkins, Ashley 4/27/15 OT 4 University of Minnesota MOT Acute

Engen, Deborah J.

9/17/2008 OT 33 Texas Women's University BS OT Massage, Admin, Short/Long-Term care,

Enloe, Katie J. 6/13/2005 COTA 13 Kirkwood Community College AS COTA Brain, Spine

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Falk Philpott, Cherie L.

12/16/1988 OT 28 University of Wisconsin - Milwaukee BS OT Acute

Forcelle, Mary 9/11/2000 OT 33 University of North DakotaBSOT

Rehab, brain spinal cord injury dysphagia

Geiszler, Lydia 2/20/17 OT Midwestern University Glendale MSOTGlaess, Patricia

4/12/2010 OT 32 College of St. Catherine BA OT Adult Physical Disabilities, Acute, Rehab

Hall, Kristin 10/31/2016 OT 5 Elizabethtown College BS MS OTR/L, MBA

Acute Care, INTENSIVE CARE UNIT, Education, CAPS

Halverson, Melissa O.

1/7/2008 OT 11 University of Minnesota MS OT Outpatient, Dysphagia, Low Vision, Acute

Hansen, Susan D.

1/1/1990 OT 39 Medical College of Virginia/Virginia Commonwealth University

BS OT Acute, Dysphagia, Cancer, Ortho Surgery Aftercare

Hatlevig, Janelle M.

12/17/2007 OT 15 College of St. Catherine MA OT Acute, Rehab (PAM Cert), TBI, Stroke, Driving after strokes, Coma, Vent, Dysphasia

Heinle, Donna 6/27/1988 OT 36 University of North Dakota BS OT, OTD, BCPR

TBI, CVA, SCI, MS, Cardiac, Research, Student Education

Jamie Hilker 5/10/2010 OT 13 University of Wisconsin-La Crosse BS OT, CHT Hands

Jeardeau, Teresa

1/14/2008 OT 20 University of Wisconsin - Madison BS OT CHT, Ortho, Aquatics, Low-vision

Johnson, Kathleen K.

10/11/1985 OT 34 College of St. Catherine BS OT Rehab, SCI, AT, Education

Toomey, Stephanie N.

9/24/2001 OT 15 College of St. Catherine BS OT Lymphedema, Hand

Korkowski, Susan L.

2/28/1994 OT 23 College of St. Catherine BS OT Acute, Work Rehab, Hand Therapy, Psych, Pain Rehab

Kotajarvi, Cindy M.

4/24/1986 OT 32 Mount Mary College BS OT Rehab, Splinting

Kranz, Sonja M.

12/16/1985 OT 32 University of North Dakota BS OT, CHT Hands

Krekelberg, Amy L.

1/14/2008 OT 11 College of St. Scholastica MA OT Rehab, Peds

Kulmeshkenov, Tastan

9/13/2010 OT 8 OT Dysphagia, Acute care

Lund, Ann T. 5/2/1984 OT 33 University of Wisconsin - Madison BS OT, CHT Hand, Lymphedema, CLT, Acute

Mattson, Megan

9/19/2016 OT U of MN Rochester MSOT Pediatrics

Miller, Scott A. 2/21/2005 OT 36 University of Wisconsin - Milwaukee MSOT OTD Neuro, IP Rehab, Dysphagia, Geri, Ortho, WC Seating/Positioning, Home Accessibility,Teaching Student Education

Minnick, Christie

4/12/2010 OT 8

Mosemann, Wendy F.

11/4/2002 OT 21 Concordia University BS OT Acute, Rehab

Erica Myers 4/7/15 OT 2 University of North Dakota MOT Out-Patient

Mulrine, Cara M.

9/4/2001 OT 15 College of St. Catherine BS OT, CHT U/E, Hand

Murphy, 1/21/2008 OT 31 College of St. Catherine BS OT lymphedema, acute

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Michelle care, palliative care, orthopedics

Nelson, Margaret C.

1/18/1984 OT 34 University of Minnesota BS OT, CHT Hand, Acute

Nelson, Sharon M.

8/22/1988 OT 28 University of Wisconsin - Milwaukee BS OT Rehab

Neubauer, Bridget L.

2/22/1999 OT 19 College of St. Catherine BS OT, CHT Acute, Hand

Neveau, Daniel D.

2/1/1999 OT 19 College of St. Scholastica MA OT Work Rehabilitation, Dysphagia

O’Connor, Jennifer

5/13/1999 COTA 17 Riverland Community & Technical College AS COTA Acute, Psych, Pain Rehab, Biofeedback

Oldenburg, Hannah

1/1/13 OT 4 St. Catherine’s University MA Acute, Home Healthcare, Education, Cardiac

Osten, Angela M.

8/21/1989 OT 31 University of Minnesota BS OT Neuro, Brain, TBI, Stroke, Rehab, Acute, Geri

Paul, Calley J. 12/1/1997 COTA 23 North Dakota State College of Science AS COTA Geri

Pinkerton, Renee

10/29/12 OT 30 College of St. Catherine’s MA, OT, MS Holistic Health Studies

Geri, Hand, Dysphagia

Petersen, Jessica L.

2/14/2005 OT 13 University of Wisconsin - LaCrosse BS OT Acute Care, Pain Rehab, Brain Rehab

Potter, Amy R. 3/6/2006 OT 18 Washington University MS OT Acute, Rehab Unit, SCI

Potter, Jonathan

1/16/2006 OT 18 Washington University MS OT Acute Care, Rehabilitation Unit, Brain Rehab

Reese, Sandra K.

6/16/1997 OT 35 University of North Dakota BS OT Peds, Acute, Hand

Richardson, Sara R.

1/4/1993 OT 25 University of Wisconsin - Madison BS OT Lymphedema, Acute, Hand, Splinting, Dysphagia

Ritter, Stephanie N.

4/2/2001 OT 17 University of Wisconsin - LaCrosse BS OT Brain Rehab, Acute, Dysphagia

Roers, Lisbeth D.

1/8/1996 COTA 22 Riverland Community College AA TBI, Pain Rehab

Carlan, Katherine M.

1/19/2009 OT 10 College of St. Scholastica MS OT Acute Care

Schiebel, Cindy J.

5/23/2005 OTR/L, BCMH

21 University of Wisconsin - Madison BS OT Mental Health, Pain Rehabilitation, BiofeedbackManagement

Shofner, Lisa M.

1/15/2007 OT 12 University of Minnesota MS OT Acute, Geri, Dysphagia, Neuro Rehab

Struss, Leah OT 9 College of St. Scholastica MA OT Acute care, Work Rehab, Lymphedema, Dysphagia

Switalski, Erin M.

12/8/2008 OT 11 Univeristy of Wisconsin - Milwaukee BS OT Spine

Szynalski, Melinda

10/13/2008 OT 26 College of St. Catherine BS OT Geri, Acute, Neuro, dysphagia, Mental Health

Theuer, Amanda

3/15/11 OT 7 Texas Woman’s University MOT Pediatrics, Management

Thorstenson, Neilee M.

5/18/1998 OT 19 University of North Dakota BS OT Neuro, Acute, Geri

Tonn, Michele OT 10 College of St. Scholastica MA OT Rehab, Pediatrics,

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traumatic brain injury, neuro

Trenary, Tamra L.

8/7/1998 OT 20 College of St. Scholastica MA OT, BCPR, OTD

Acute, Mental Health, Pain Rehab, Industrial Rehab, Student Education

VanSoest, Laurel Ann

1/31/11 OT 6 Midwestern University MOT Pain Rehab, Psych, Acute

Vareberg, Barb J.

8/5/1996 OT 27 College of St. Catherine BS OT Adult Neuro, Student Education

Vitse, Merri L. 1/3/1995 COTA 22 Austin Community College/ BS Degree from Concordia College in Rehabilitation Science

AS COTA TBI, Pain Rehab, Acute, Psych

Vos-Draper, Tamara L.

11/12/2001 OT 24 College of St. Catherine BS OT WC Seating

Walb, LeeAnn 8/1/16 OT 2 Winston Salem State University MSOT Pediatrics

Walch, Sara 5/20/2002 OT 13 College of St. Catherine MA OT Brain OP, Rehab, Acute

7. Describe the training provided for OT staff for effective supervision of students (check all that apply). ACOTE Standards B.7.10, B.10.1, B.10.3, B.10.12,B.10.13, B.10.17, B.10.18, B.10.19, B.10.20, B.10.21

Supervisory models Training on use of FW assessment tools (such as the AOTA Fieldwork Performance Evaluation- FWPE, Student Evaluation of Fieldwork Experience–SEFWE, and the Fieldwork Experience Assessment Tool–FEAT)

Clinical reasoning Reflective practice

Comments: All fieldwork educators are encouraged to attend the AOTA Fieldwork Educator Certificate Workshop. Currently Donna Heinle and Tamra Trenary are regional trainers for the AOTA Fieldwork Educator Certificate Workshop.

8. Please describe the process for record keeping of supervisory sessions with a student, the student orientation process to the agency, OT services, and the fieldwork experience. ACOTE Standards C.1.2, C.1.3, C.1.10     

Supervisory Patterns–Description (respond to all that apply)1:1 Supervision model: direct supervision for intensive care unit patients Multiple students supervised by one supervisor: 3:1 model Collaborative supervision model: 3:1 model Multiple supervisors share supervision of one student; number of supervisors per student:     Non-OT supervisors:      

9. Describe funding and reimbursement sources and their impact on student supervision.Students are not allowed to work with patients that are insured through Medicaid and this may have an impact on student supervision. Medicare A/B guidelines,, Medicaid, and Third Party PayersSTATUS/TRACKING INFORMATION SENT TO FACILITY:

Date: 5/19/2015ACOTE Standard C.1.6

Which documentation does the fieldwork site need? Fieldwork Agreement/Contract?     

OR Memorandum of Understanding (MOU)?      

Which FW Agreement will be used? OT Academic Program Fieldwork Agreement Fieldwork Site Agreement/ Contract

Title of Parent Corporation (if different from facility name):      

Type of business organization (Corporation, partnership, sole proprietor, etc.):      

State of incorporation:      

Fieldwork site agreement negotiator:       Phone:       Email:      

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Address (if different from facility):Street:      City:       State:       Zip:      

Name of student: Potential start date for fieldwork: This is all sent through Mayo School of Health Science and the CCCE Donna Heinle OTD,OTR/L, BCPR using our own forms.

Any notation or changes that you want to include in the initial contact letter: No

Information Status ACOTE Standards C.1.1, C.1.2, C.1.3, C.1.8,

New general facility letter sent:      Level I Information Packet sent:      Level II Information Packet sent:      Mail contract with intro letter (sent):      Confirmation sent:      Model behavioral objectives:       Week-by-week outline:      Other information:       Database entry:      Facility information:       Student fieldwork information:       Make facility folder:       Print facility sheet:      

Revised 5/8/2023

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