CPCC Level I Fieldwork Educator Information Form
Each Fieldwork Educator (FWE) must complete the following form PRIOR to taking a CPCC OTA Fieldwork student. If one FWE takes multiple CPCC OTA students, complete this form once. If any information changes, please resubmit the form. Thank you for supporting our students!
Email address *
Last name *
Your answer
First name *
Your answer
Professional Credentials *
Number of years practicing in your field *
Your answer
Current Position and Title
Your answer
Current Employer(s)
Your answer
Number of years at current facility
Your answer
In which state(s) are you licensed?
Please enter your professional license number
Your answer
Please enter your professional license expiration date.
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DD
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YYYY
Mailing Address
We use your mailing address to send CEU certificates after the fieldwork is complete. You may use your home address or the facility address - whatever you prefer.
Your answer
CEU Preference *
Please list any additional experiences that qualify you to supervise OTA students.
Your answer
THANK YOU!
We appreciate your dedication to the field of OT, as evidenced by your commitment to educating future OTAs!
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