<p> Personal Data Sheet for Student Fieldwork Experience Page 2</p><p>PERSONAL DATA SHEET</p><p>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.</p><p>Louisiana State University-Shreveport Personal Data Sheet for Student Fieldwork Experience Page 2 Occupational Therapy Fieldwork Student PERSONAL DATA SHEET</p><p>PERSONAL INFORMATION</p><p>Name:______</p><p>Permanent Home Address: ______</p><p>______</p><p>Home Phone:______Cell phone: ______</p><p>Email: ______</p><p>Emergency Contact: (name, address, phone) ______</p><p>______</p><p>EDUCATION INFORMATION: 1. Expected Date of Graduation for Master of Occupational Therapy Degree:______</p><p>Group Research ___or Thesis___ Topic: ______</p><p>2. Previous colleges or universities attended (include year and degree): ______</p><p>______</p><p>3. Foreign languages read: ______spoken:______</p><p>4. Do you hold a current CPR certification card? Yes___ No___ Date of expiration:______</p><p>LIABILITY INSURANCE (attach a copy of policy) 1. Malpractice/Professional Liability Insurance Company:______</p><p>Policy Number: ______Expiration Date: ______</p><p>HEALTH INFORMATION 1. Are you currently covered under any health insurance? Yes _____ No _____</p><p>2. If yes, name of Health Insurance Company: ______</p><p>Group Number: ______Subscriber Name: ______</p><p>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)</p><p>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 </p><p>______</p><p>______</p><p>CAREER GOALS ______</p><p>______</p><p>PERSONAL PROFILE 1. Strengths: _____</p><p>2. Special skills or interests: ______</p><p>3. Describe your preferred learning style: ______</p><p>4. Describe your preferred style of supervision: ______</p><p>5. Will you need housing during your affiliation? Yes _____ No _____</p><p>6. Will you have your own transportation during your affiliation? Yes _____ No _____</p><p>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: ______</p><p>______</p><p>FIELDWORK EXPERIENCE SCHEDULE</p><p>TYPE OF DATES & LENGTH FW SITE FW EXPERIENCE OF FW EXPERIENCE</p><p>Level I Exp.</p><p>Level II Exp.</p><p>ADDITIONAL COMMENTS Personal Data Sheet for Student Fieldwork Experience Page 2</p><p>Student Signature: ______Date: ______</p>