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 Name: *
Your answer
Facility Phone Number: *
Your answer
Facility Address: *
Your answer
Facility Hours
Your answer
Accrediting Body:
Your answer
Date of Last Accreditation:
MM
/
DD
/
YYYY
Program Director or Chief Administrator Name:
Your answer
Type of facility:
Your answer
Age of population served:
Check all that apply
Possible programs for student involvement:
Your answer
Facility Specific Prerequisites:
All CPCC OTA Students are required to complete specific health record information. Please see the following link for Health Record requirements: https://www.cpcc.edu/health_sciences/ota/program-fieldwork-for-fieldwork-sites-only/level-i-level-ii-fieldwork-guidelines/FWHealthRecords.pdf
Additional Immunizations/tests (specify type)
Your answer
Any other requirements?
Your answer
Dress code
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.
Your answer
Information for Students
Lunch Available for students?
Student Fieldwork Hours
Your answer
Any other information you feel would be helpful to students?
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of CPCC - Employees. Report Abuse - Terms of Service