Physical and
Occupational Therapy

FIELDWORK DATA FORM

Thank you for supporting occupational therapy education! On this page, you can download the most current Fieldwork Data Form (FWDF) and Years of Experience Form. In order to maintain accreditation of our program, these forms should be updated yearly by the clinical sites affiliated with ISU for Level I and Level II fieldwork experiences. These documents tell us and other occupational therapy programs about your clinic, your therapists, and the clinical education opportunities available. After completing the FWDF and Years of Experience Form, please email them to my assistant, Will Fraser, at fraswill@isu.edu. Do not forget to complete the following questionnaire as well.

On behalf of the Master of Occupational Therapy program at Idaho State University, I thank you most sincerely for your willingness to provide clinical opportunities for our students. Your dedication and generosity are both appreciated, and truly do make a difference in future occupational therapists.

Sincerely,

Kimberly Lloyd, MOTR/L
Academic Fieldwork Coordinator

Fieldwork Data Form (downloadable document)
Years of Experience Form (downloadable document)
Email completed forms to fraswill@isu.edu

Name of Clinic:
Mailing address:
City:
State:
Zip code:
Phone number:
Fax number:
Occupational therapy contact:
Phone number:
Email address:
What types of services do you offer?
Do you offer physical therapy services?
Yes No
Do you offer speech pathology services?
Yes No
What percentage of your interventions are spent addressing Mental Health, Social and/or Psychological needs of your clients?

Indicate which fieldwork experiences your clinic/facility might be able to host students. Please keep in mind that an occupational therapists must have at least one year working experience to serve in the role of fieldwork educator.

Level I (2 weeks, May)
Yes No Not sure
Level I (2 weeks, December)
Yes No Not sure
Level II (12 weeks, May-Aug)
Yes No Not sure
Level II (12 weeks, Jan-Mar)
Yes No Not sure

Idaho State University • 921 South 8th Avenue • Pocatello, Idaho, USA 83209
About ISU
Contact ISU

Idaho State University

Physical and Occupational Therapy

FIELDWORK DATA FORM

Physical and
Occupational Therapy