Personal Data Sheet s1

Personal Data Sheet for Student Fieldwork Experience Page 2

PERSONAL DATA SHEET

This form is completed by the student and is sent to the student’s Level II fieldwork educator prior to the start of the fieldwork experience.

Louisiana State University-Shreveport Personal Data Sheet for Student Fieldwork Experience Page 2 Occupational Therapy Fieldwork Student PERSONAL DATA SHEET

PERSONAL INFORMATION

Name:______

Permanent Home Address: ______

______

Home Phone:______Cell phone: ______

Email: ______

Emergency Contact: (name, address, phone) ______

______

EDUCATION INFORMATION: 1. Expected Date of Graduation for Master of Occupational Therapy Degree:______

Group Research ___or Thesis___ Topic: ______

2. Previous colleges or universities attended (include year and degree): ______

______

3. Foreign languages read: ______spoken:______

4. Do you hold a current CPR certification card? Yes___ No___ Date of expiration:______

LIABILITY INSURANCE (attach a copy of policy) 1. Malpractice/Professional Liability Insurance Company:______

Policy Number: ______Expiration Date: ______

HEALTH INFORMATION 1. Are you currently covered under any health insurance? Yes _____ No _____

2. If yes, name of Health Insurance Company: ______

Group Number: ______Subscriber Name: ______

3. Date of last Tine Test or chest x-ray: ______Personal Data Sheet for Student Fieldwork Experience Page 2 (If positive for TB, tine test is not given)

Fieldwork F-D G: 12-08 Personal Data Sheet Personal Data Sheet for Student Fieldwork Experience Page 2 PREVIOUS WORK/VOLUNTEER EXPERIENC E RELATED TO OT

______

CAREER GOALS ______

______

PERSONAL PROFILE 1. Strengths: _____

2. Special skills or interests: ______

3. Describe your preferred learning style: ______

4. Describe your preferred style of supervision: ______

5. Will you need housing during your affiliation? Yes _____ No _____

6. Will you have your own transportation during your affiliation? Yes _____ No _____

7. Do you require any reasonable accommodations (as defined by ADA) to complete your fieldwork? Yes ___ No ____ If yes, were there any reasonable accommodations that you successfully used in your academic courses that you would like to continue during fieldwork? If so, list them: ______

______

FIELDWORK EXPERIENCE SCHEDULE

TYPE OF DATES & LENGTH FW SITE FW EXPERIENCE OF FW EXPERIENCE

Level I Exp.

Level II Exp.

ADDITIONAL COMMENTS Personal Data Sheet for Student Fieldwork Experience Page 2

Student Signature: ______Date: ______