<p> FIELDWORK DATA FORM</p><p>This form refers to: Occupational Therapists and COTA’s fieldwork experience.</p><p>Length of Fieldwork: OT: Varies according to level and student needs COTA: Varies</p><p>Will Accept: X Full-Time Student(s) 0 Part-Time Student(s) X 1st Placement X 2nd Placement X 3rd Placement</p><p>Name of Center: Vanderbilt Bill Wilkerson Center – Pediatric OT</p><p>Address/City/State/Zip: 1215 21 st Ave. South, Suite 6209 Medical Center East- South Tower Nashville, Tennessee 37232-8590 .</p><p>Center Phone: (615-936-5218) E-Mail Address: [email protected] Person Responsible for Fieldwork Program:</p><p>Name : Vicki Scala Credentials: MS, OTR/L, Staff Level IV Therapist Phone: (615)936-5218</p><p>Staff: 4 OTR(s) 0 COTA(s) 0 Support Staff Approximate # of Contracts with Schools: 5</p><p>Accreditation By: JCAHO Date: June, 2006</p><p>GENERAL INFORMATION</p><p>Setting Description of Specialty</p><p>__ Hospital (e.g. Acute inpt, Outpt, Rehab Unit) ______School (e.g. Public School System)______Community Agency (e.g. Psycho-Social Program, Homeless Shelter)______Private Practice (e.g. Pediatric, Psych, Home Health)______Residential Program (e.g. Developmental Delay, Mental Retardation)______Nursing Home (e.g. Rehab Unit, Long Term Care)______X__OTHER Pediatric Out-Patient Clinic </p><p>Ages Served: 0-5 Years 6-12 Years X 13-21 Years X Adult X Older Adult</p><p>Primary Conditions for Which Occupational Therapy is Administered</p><p>___Adjustment Disorder __CVA/Hemiplegia X Neuromuscular Disorders Affective Disorder _X_Degenerative Neuro Disorder Neonatology __ Alzheimer’s Disease X Developmental Disorder X Oncology __ Amputee _ Dementia Personality Disorder __ Anxiety Disorder __ Diabetes X Pervasive Developmental Disorder __Arthritis X Dysphagia/Feeding Disorders __ Respiratory Disease X Autism/PDD Eating Disorders Schizophrenic Disorder __ Back Injury _X_ Eating/Feeding Problems __Spinal Cord Injury __ Burns __ Fractures & Gen. Orthopedics Substance Abuse __Cardiac Dysfunction __ Hand/Wrist Disorders __ Traumatic Brain Injury X Cerebral Palsy X Hearing Disability __Visual Disability Chronic Pain __ HIV/Aids Well Population X Congenital Anomalies X Learning Disorder Ergonomics X Mental Retardation Page #2 Fieldwork Data Form ASSESSMENTS AND INTERVENTIONS</p><p>1. Assessments: All of medical center medical records (including all OT evaluations, treatment plans and daily notes) are computerized. </p><p>2. Intervention: Role of OT in Fieldwork setting: X Direct X In-Direct Describe Intervention: ADL’s – Feeding for sensory-based deficits, developmental teaching. Neuromusculosketetal – Strengthening, range of motion, postural control and muscle tone. . Motor – Bilateral integration, praxis. Gross and fine motor coordination, visual motor control . Sensory - Sensory awareness and processing ; perceptual processing Discharge Planning – With family to address on-going therapy, home programs and/or community-based service options</p><p>Theoretical Model(s) Guiding Practice: NDT, Sensory Integration/Sensory Processing Theory, Occupational Performance Model + Motor Learning\</p><p>PRE-REQUISITES</p><p>X CPR Physical Exam X Pediatric CPR (if affiliation in Peds) X Criminal Background Check X Universal Precautions (OSHA) Fingerprinting __ Interview X Malpractice Inusrance _ Car Required X Health Insurance X Immunizations/Tests - Specify Type: X Other See Vanderbilt University Medical Center The Academic Fieldwork Coordinator Student/Instructor Health Screening and must communicate via writing or Pre-requisite Checklist. Verbally with Vicki Scala, MS, OTR/L, X Fieldwork Experience - Indicate Type: Clinical Coordinator, to assign students.</p><p>STUDENT INFORMATION</p><p>NO Room Provided Meals: N/A _____on grounds ____Breakfast _____Lunch _____Dinner</p><p>YES Will assist student to find housing off campus with prices ranging from $300-$700/month.</p><p>Therapists are off major holidays.. No weekends. Students are expected to work the same schedules as his/her clinical instructor.</p><p>Dates: Use AOTA Suggested Dates: X Use Own Dates: X . Page #3 Fieldwork Data Form</p><p>STUDENT SUPERVISION</p><p>Check all that apply: X 1:1 Model Multiple Students: One Supervisor X Multiple Supervisors: One Student (no more than 3 supervisors)</p><p>Students are given the opportunity to spend days with therapists in other areas/facilities (ex: Vanderbilt Children’s Hospital, Susan Gray School for Children, etc. Students have the opportunity to attend rounds and other medical center-based continuing education.</p><p>Structure Provided to Students: Low High 1 2 3 (4) 5</p><p>Students are provided with week-to-week guidelines and objectives.</p><p>Nature of Supervision Specific to different CI’s : Low High 1 2 3 (4) 5</p><p>Ending Student Expectation/Productivity: Varies Number of Clients per Week __62% Productivity Expected (OT’s) __Productivity Expected (COTA’s)</p><p>By the end of week 9 students are expected to be functioning as entry-level therapists/</p><p>Function as an entry-level therapist: OT’s = 5 hours of productivity/day – approximately 24 RVU’s/week</p><p>R.V.U.’s Relative Value Units (60 minutes of time)</p><p>NAME TITLE DEGREE AND YEARS OT COLLEGE/UNIVERSITY IN OT SPECIALTY Vicki Scala OTR MS. Belmont University 30 Pediatrics; SIPT BS, Va. Commonwealth University Cert.; Feeding Elizabeth Murillo OTR MS, Chatham University 8 Pediatrics, School system Robin Hammond OTR BS, Eastern Kentucky 18 Pediatrics, School System, Feeding Katy Richardson OTR MS, Washington University 4 Pediatrics</p><p>Vanderbilt University Medical Center is a comprehensive health care facility dedicated to patient care, research and education. It’s reputation for excellence in each of the areas has made Vanderbilt a major patient referral center for the Mid-South. Each year over 300,000 people choose Vanderbilt University Medical Center for their health care needs. Vanderbilt University Medical Center is a twin towered, 658-bed structure with the most up-to-date systems and technology. The hospital is also home to the region’s only Level I Trauma Center, Burn Unit and the most comprehensive Neonatal Intensive Care Unit. Page #4 Fieldwork Data Form VANDERBILT UNIVERSITY MEDICAL CENTER REHABILITATION SERVICES MISSION STATEMENT</p><p> To maximize functional independence by providing up-to-date, customer focused and cost effective treatment to our patients.</p><p> To encourage and emphasize each patient’s role as an active participant in their own care and rehabilitation.</p><p> To keep our referral sources informed on patient’s progress by concise, accurate and timely evaluations and progress reports.</p><p> To provide out patients and communities with preventative education and safe methods to perform daily activities.</p><p> To provide well-organized clinical education experiences for rehabilitation professionals and students.</p><p> To be active consumers of, and participants in rehabilitation research.</p><p>AOTA Commission on Education (ICOE and Fieldwork Issues Committee (FWIC) Amended and Approved by FWIC 11/99 and COE 12/99.</p><p>July 2007/vs</p>