Level I Fieldwork Data Form
If your facility hosts CPCC OTA students for Level I fieldwork only, please complete this form. If your facility hosts Level I and Level II fieldwork students, please complete the Level II Fieldwork data form.
General Facility/Site Information
Facility Phone Number:
Date of Last Accreditation:
Program Director or Chief Administrator Name:
Type of facility:
Age of population served:
Check all that apply
Possible programs for student involvement:
Facility Specific Prerequisites:
All CPCC OTA Students are required to complete specific health record information. Please see the following link for Health Record requirements:
Additional Immunizations/tests (specify type)
Any other requirements?
CPCC OTA students are expected to wear a green collared and monogrammed shirt with a CPCC OTA student ID. Full length dress pants, khakis, or scrub pants and close-toed shoes are also expected. If you have different, or additional dress code requirements, please list them here.
Information for Students
Lunch Available for students?
Student Fieldwork Hours
Any other information you feel would be helpful to students?
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