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!
Number of years practicing in your field
Current Position and Title
Number of years at current facility
In which state(s) are you licensed?
Please enter your professional license number
Please enter your professional license expiration date.
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.
I prefer a PDF certificate sent to the email address listed above.
I prefer a paper certificate sent to the mailing address listed above.
I do not require a CEU certificate.
Please list any additional experiences that qualify you to supervise OTA students.
We appreciate your dedication to the field of OT, as evidenced by your commitment to educating future OTAs!
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