Department of Occupational Therapy & Occupational Science

TOWSON UNIVERSITY

DEPARTMENT OF OCCUPATIONAL THERAPY & OCCUPATIONAL SCIENCE

LEVEL II FIELDWORK REQUEST FORM

MS15 COHORT

Date: TU Student # ______

NAME TU email:

ADDRESS: (Local) Phone:

Cell:______

Fax:______

(Permanent) Phone:

PRIOR DEGREE(S) (What, Where, When)

WORK EXPERIENCE (Brief overview)

TIME FRAME for Level II Fieldwork Placements

#1: June 26 – Sept. 25, 2017 (date subject to change)

#2: September 25 – December 15, 2017 (date subject to change)

1. LOCATION PREFERENCES (e.g., specific states, no preference)

2. TYPE OF FIELDWORK

a) State any particular areas of interest

Name:______TU Email:______

b) Facility type preferred (i.e., acute care, sub-acute, rehab, long term care;

teaching hospital, community hospital, out-patient facility; large or small).

3. Supervision/Structure

a) Explain your supervision preferences and needs.

b) Programs and settings differ in pace/speed; what is your preference?

c) List any specific types of learning experiences desired.

d) Do you tend to prefer to work in a large or a small group?

4. Personal Concerns & Considerations

a) Physical limitations

b) Three strengths

c) Three present areas of deficit (things you are currently working on)

d) Date you completed the Learning Style Survey:______

Discuss your learning style (e.g., detail vs. big picture, learn through hands-on

experience, independent learner, need for structure).

e) If you have been a patient in a particular facility, please state:

Name:______TU Email:______

f) Do you plan to request accommodations? ( Must be registered with Disability Support

Services (DSS) 7720 York Road, Suite 232, 410/704-2638 (Voice or TDD).

5. If you are an OTA please list previous 2 mo. fieldwork sites:

Psych:

Phys Dis:

6. PREFERENCES:

After a careful review of the fieldwork files, located outside room 108, and on the fieldwork web page, list below the type of facility preferred for your Level II placements. If you are interested in a facility where we do not have an agreement, follow the steps given in the online Fieldwork Manual for contacting a new facility. Sites where students or members of their immediate family have an employment history should not be included. This information will be used to make reservations for TU students. Only those students who check Baltimore-Washington facility types (i.e., within 90 miles of the University) will be assigned via lottery. Changes in requests after the deadline will be considered an alternate plan and will be assigned FW placements on a space available basis.

A. Baltimore-Washington area placements only.

Check preferred facility type:

Physical Rehabilitation

□Acute (e.g., Hopkins, GBMC, St. Joseph, Mt. Washington Hospital )

□ Rehab (e.g., NRH, Kernan, Adventist Rehab, Kennedy Krieger)

□ Long term care (e.g., Manor Care, Future Care, Genesis )

Psychosocial Rehabilitation

□ Acute (e.g., St. Joseph, Johns Hopkins, Howard County Hospital )

□Long term care (e.g., Springfield, Spring Grove, VA Perry Point)

□Day Programs (e.g., Mosaics, Sheppard Pratt, Ivy Mount )

Name:______TU Email:______

B. Out-of-State and Study Abroad Sites ONLY

Please list three site options for each:

Physical rehabilitation

Psychosocial rehabilitation

Thanks for your time in completing this form. Please return it to me in hard copy by COB, MONDAY, JANYARY 26, 2016. I realize you may be unsure of even how to respond to some questions at this point. However, as you learn more, please update information with me personally.

I will be meeting periodically with you as a group and I am available to meet individually to present and clarify options that might assist in your decision-making. You may schedule an appointment with me by adding your name, cohort, & email address to the sign up sheet on my office door (room 246).

Thank you.

Jerry Bentley, MS, OTR/L, FAOTA

Academic Fieldwork Coordinator

(410) 704-2253