ࡱ> _ bjbj(( <B8\B8\BZ% :::::NNN8dN *3333$5K U`$;: _$5$5 _ _::334Oububub _:3:3ub _ububt3Ci_^8te0\`<pt:t"[[ub|\t\"["["[Qa$"["["[ _ _ _ _"["["["["["["["["[ > :  AOTA FIELDWORK DATA FORM Introduction: The purpose of the Fieldwork Data Form is to facilitate communication between occupational therapy (OT) and occupational therapy assistant (OTA) academic programs, OT/ OTA students, and fieldwork educators. Fieldwork Educators and Academic Fieldwork Coordinators (AFWC) jointly complete the Fieldwork Data Form to describe the fieldwork setting where students may have placements. While much of the information may be completed by the Fieldwork Educator, there will be additional information best obtained through AFWC interview of the fieldwork education coordinator at the site. The AFWC will find opportunity to document fieldwork related Accreditation Council for Occupational Therapy (ACOTE) Standards that support the ACOTE on-site accreditation review process. In addition, OT/ OTA students will find valuable information describing the characteristics of the fieldwork setting, the client population, commonly used assessments, interventions, and expectations and opportunities for students. The Fieldwork Data Form has been developed to reflect the Occupational Therapy Practice Framework terminology and best practice in occupational therapy to promote quality fieldwork experiences. It was developed through the joint efforts of the Commission on Education (COE) and Education Special Interest Section (EDSIS) Fieldwork Subsection with input from many dedicated AFWCs and fieldwork educators. AOTA FIELDWORK DATA FORM Date:  FORMTEXT 10/6/2014 Name of Facility:  FORMTEXT Shore Rehabilitation Institute Address: Street  FORMTEXT 425 Jack Martin Blvd City  FORMTEXT Brick State  FORMTEXT NJ Zip:  FORMTEXT 08724 FW IFW IIContact Person:  FORMTEXT Rachelle Mikita FORMTEXT      Credentials:  FORMTEXT OTRContact Person:  FORMTEXT Rachelle MikitaCredentials:  FORMTEXT OTRPhone:  FORMTEXT 732-836-4500 E-mail:  FORMTEXT rspensermakita@meridianhealth.comPhone:  FORMTEXT 732-836-4500 E-mail:  FORMTEXT rspencermakita@neridianhealth.com FORMTEXT       Director:  FORMTEXT Becky MuroskiInitiation Source:  FORMCHECKBOX  FW Office  FORMCHECKBOX  FW Site  FORMCHECKBOX  StudentCorporate Status:  FORMCHECKBOX  For Profit  FORMCHECKBOX  Non-Profit  FORMCHECKBOX  State Gov t  FORMCHECKBOX  Federal Gov tPreferred Sequence of FW: ACOTE Standards B.10.6  FORMCHECKBOX  Any  FORMCHECKBOX  Second/Third only; 1st must be in:  FORMTEXT        FORMCHECKBOX  Full-time only  FORMCHECKBOX  Part-time option  FORMCHECKBOX  Prefer Full-timePhone:  FORMTEXT 732-836-4518Fax:  FORMTEXT 732-836-4531Web site address:  FORMTEXT www.shorerehabilitationinstitute.com OT Fieldwork Practice Settings (ACOTE Form A #s noted) :Hospital-based settingsCommunity-based settingsSchool-based settingsAge Groups:Number of Staff: FORMCHECKBOX  In-Patient Acute1.1  FORMCHECKBOX  In-Patient Rehab 1.2  FORMCHECKBOX  SNF/ Sub-Acute/ Acute Long-Term Care 1.3  FORMCHECKBOX  General Rehab Outpatient 1.4  FORMCHECKBOX  Outpatient Hands 1.5  FORMCHECKBOX  Pediatric Hospital/Unit 1.6  FORMCHECKBOX  Peds Hospital Outpatient 1.7  FORMCHECKBOX  In-Patient Psych1.8 FORMCHECKBOX  Peds Community 2.1  FORMCHECKBOX  Behavioral Health Community 2.2  FORMCHECKBOX  Older Adult Community Living 2.3  FORMCHECKBOX  Older Adult Day Program 2.4  FORMCHECKBOX  Outpatient/hand private practice 2.5  FORMCHECKBOX  Adult Day Program for DD 2.6  FORMCHECKBOX  Home Health 2.7  FORMCHECKBOX  Peds Outpatient Clinic 2.8 FORMCHECKBOX  Early Intervention 3.1  FORMCHECKBOX  School 3.2 Other area(s) please specify:  FORMTEXT       FORMCHECKBOX  0-5  FORMCHECKBOX  6-12  FORMCHECKBOX  13-21  FORMCHECKBOX  22-64  FORMCHECKBOX  65+OTRs:  FORMTEXT 12 COTAs:  FORMTEXT 0 Aides:  FORMTEXT 4 PT:  FORMTEXT 14 Speech:  FORMTEXT 4 Resource Teacher:  FORMTEXT     Counselor/Psychologist:  FORMTEXT     Other:  FORMTEXT     Student Prerequisites (check all that apply) ACOTE Standard B.10.6Health requirements: FORMCHECKBOX  CPR  FORMCHECKBOX  Medicare / Medicaid Fraud Check  FORMCHECKBOX  Criminal Background Check  FORMCHECKBOX  Child Protection/abuse check  FORMCHECKBOX  Adult abuse check  FORMCHECKBOX  Fingerprinting FORMCHECKBOX  First Aid  FORMCHECKBOX  Infection Control training  FORMCHECKBOX  HIPPA Training  FORMCHECKBOX  Prof. Liability Ins.  FORMCHECKBOX  Own transportation  FORMCHECKBOX  Interview FORMCHECKBOX  HepB  FORMCHECKBOX  MMR  FORMCHECKBOX  Tetanus  FORMCHECKBOX  Chest x-ray  FORMCHECKBOX  Drug screening  FORMCHECKBOX  TB/Mantoux FORMCHECKBOX  Physical Check up  FORMCHECKBOX  Varicella  FORMCHECKBOX  Influenza Please list any other requirements:  FORMTEXT Criminal background check going back 5 years from states you currently live, work & go to school Must have 2 step Mantoux screening Proof of flu vaccine required if interning from Nov 1 - March 31 or will need to wear mask  Performance skills, patterns, contexts and client factors addressed in this setting (check all that apply)Performance Skills: Motor Skills  FORMCHECKBOX  Posture  FORMCHECKBOX  Mobility  FORMCHECKBOX  Coordination  FORMCHECKBOX  Strength & effort  FORMCHECKBOX  Energy Process Skills  FORMCHECKBOX  Energy  FORMCHECKBOX  Knowledge  FORMCHECKBOX  Temporal organization  FORMCHECKBOX  Organizing space & objects  FORMCHECKBOX  Adaptation Communication/ Interaction Skills  FORMCHECKBOX  Physicality- non verbal  FORMCHECKBOX  Information exchange  FORMCHECKBOX  RelationsClient Factors: Body functions/structures  FORMCHECKBOX  Mental functions- affective  FORMCHECKBOX  Mental functions-cognitive  FORMCHECKBOX  Mental functions- perceptual  FORMCHECKBOX  Sensory functions & pain  FORMCHECKBOX  Voice & speech functions  FORMCHECKBOX  Major organ systems: heart, lungs, blood, immune  FORMCHECKBOX  Digestion/ metabolic/ endocrine systems  FORMCHECKBOX  Reproductive functions  FORMCHECKBOX  Neuromusculoskeletal & movement functions  FORMCHECKBOX  SkinContext(s):  FORMCHECKBOX  Cultural- ethnic beliefs & values  FORMCHECKBOX  Physical environment  FORMCHECKBOX  Social Relationships  FORMCHECKBOX  Personal- age, gender, etc.  FORMCHECKBOX  Spiritual  FORMCHECKBOX  Temporal- life stages, etc.  FORMCHECKBOX  Virtual- simulation of env, chat room, etc. Performance Patterns/Habits  FORMCHECKBOX  Impoverished habits  FORMCHECKBOX  Useful habits  FORMCHECKBOX  Dominating habits  FORMCHECKBOX  Routine sequences  FORMCHECKBOX  Roles Most common services priorities (check all that apply) FORMCHECKBOX  Direct service  FORMCHECKBOX  Discharge planning  FORMCHECKBOX  Evaluation FORMCHECKBOX  Meetings(team, department, family)  FORMCHECKBOX  Client education  FORMCHECKBOX  Intervention  FORMCHECKBOX  Consultation  FORMCHECKBOX  In-service training  FORMCHECKBOX  Billing  FORMCHECKBOX  Documentation  Types of OT Interventions addressed in this setting (check all that apply): * ACOTE Standards A.5.3, B.10.1, B.10.3, B.10.11, B.10.13, B.10.15, B.10.19, B.10.20 Occupation-based activity- within clients own environmental context; based on their goals addressed in this setting (check all that apply): *ACOTE Standards A.5.3, B.10.1, B.10.3, B.10.11, B.10.13, B.10.15, B.10.19, B.10.20Activities of Daily Living (ADL)Instrumental Activities of Daily Living (IADL)Education FORMCHECKBOX  Bathing/showering  FORMCHECKBOX  Bowel and bladder mgmt  FORMCHECKBOX  Dressing  FORMCHECKBOX  Eating  FORMCHECKBOX  Feeding  FORMCHECKBOX  Functional mobility  FORMCHECKBOX  Personal device care  FORMCHECKBOX  Personal hygiene & grooming  FORMCHECKBOX  Sexual activity  FORMCHECKBOX  Sleep/rest  FORMCHECKBOX  Toilet hygiene FORMCHECKBOX  Care of others/pets  FORMCHECKBOX  Child rearing  FORMCHECKBOX  Communication device use  FORMCHECKBOX  Community mobility  FORMCHECKBOX  Financial management  FORMCHECKBOX  Health management & maintenance  FORMCHECKBOX  Home establishment & management  FORMCHECKBOX  Meal preparation & clean up  FORMCHECKBOX  Safety procedures & emergency responses  FORMCHECKBOX  Shopping FORMCHECKBOX  Formal education participation  FORMCHECKBOX  Exploration of informal personal education needs or interests  FORMCHECKBOX  Informal personal education participationWork  FORMCHECKBOX  Employment interests & pursuits  FORMCHECKBOX  Employment seeking and acquisition  FORMCHECKBOX  Job performance  FORMCHECKBOX  Retirement preparation & adjustment  FORMCHECKBOX  Volunteer exploration / participationPlayLeisureSocial Participation FORMCHECKBOX  Play exploration  FORMCHECKBOX  Play participation FORMCHECKBOX  Leisure exploration  FORMCHECKBOX  Leisure participation FORMCHECKBOX  Community  FORMCHECKBOX  Family  FORMCHECKBOX  Peer/friendPurposeful Activity- therapeutic context leading to occupation, practice in preparation for natural context  FORMCHECKBOX  Practicing an activity  FORMCHECKBOX  Simulation of activity  FORMCHECKBOX  Role Play Examples:  FORMTEXT      Preparatory Methods- preparation for purposeful & occupation-based activity  FORMCHECKBOX  Sensory-Stimulation  FORMCHECKBOX  Physical agent modalities  FORMCHECKBOX  Splinting  FORMCHECKBOX  Exercise Examples:  FORMTEXT       Therapeutic Use-of-Self- describe  FORMTEXT working closely with clients involves integrating self with the clients needs, values, and interests Consultation Process- describe  FORMTEXT       Education Process- describe  FORMTEXT educating clients and assessment of carryoverMethod of Intervention Direct Services/case load for entry-level OT  FORMCHECKBOX  One-to-one:  FORMTEXT        FORMCHECKBOX  Small group(s):  FORMTEXT        FORMCHECKBOX  Large group:  FORMTEXT       Discharge Outcomes of clients (% clients)  FORMCHECKBOX  Home  FORMCHECKBOX  Another medical facility  FORMCHECKBOX  Home HealthOutcomes of Intervention *  FORMCHECKBOX  Occupational performance- improve &/ or enhance  FORMCHECKBOX  Client Satisfaction  FORMCHECKBOX  Role Competence  FORMCHECKBOX  Adaptation  FORMCHECKBOX  Health & Wellness  FORMCHECKBOX  Prevention  FORMCHECKBOX  Quality of Life OT Intervention Approaches  FORMCHECKBOX  Create, promote (health promotion)  FORMCHECKBOX  Establish, restore, remediation  FORMCHECKBOX  Maintain  FORMCHECKBOX  Modify, compensation, adaptation  FORMCHECKBOX  Prevent, disability preventionTheory/ Frames of Reference/ Models of Practice  FORMCHECKBOX  Acquisitional  FORMCHECKBOX  Biomechanical  FORMCHECKBOX  Cognitive- Behavioral  FORMCHECKBOX  Coping  FORMCHECKBOX  Developmental  FORMCHECKBOX  Ecology of Human Performance  FORMCHECKBOX  Model of Human Occupation (MOHO)  FORMCHECKBOX  Occupational Adaptation  FORMCHECKBOX  Occupational Performance Model  FORMCHECKBOX  Person/ Environment/ Occupation (P-E-O)  FORMCHECKBOX  Person-Environment-Occupational Performance  FORMCHECKBOX  Psychosocial  FORMCHECKBOX  Rehabilitation frames of reference  FORMCHECKBOX  Sensory Integration  FORMCHECKBOX  Other (please list):  FORMTEXT       Please list most common screenings and evaluations used in your setting:  FORMTEXT ROM, MMT, Modified Ashworth, Cognitive, Vision, Perceptual Motor, CAM, KELS, MoCA, MVPT, Wheelchair seating and Postioning, Wheelchair Assessments  Identify safety precautions important at your FW site FORMCHECKBOX  Medications  FORMCHECKBOX  Post-surgical (list procedures)  FORMCHECKBOX  Contact guard for ambulation  FORMCHECKBOX  Fall risk  FORMCHECKBOX  Other (describe):  FORMTEXT sternal, hip, cardiac,  FORMCHECKBOX  Swallowing/ choking risks  FORMCHECKBOX  Behavioral system/ privilege level (locked areas, grounds)  FORMCHECKBOX  Sharps count  FORMCHECKBOX  1:1 safety/ suicide precautionsPlease list how students should prepare for a FW II placement such as doing readings, learn specific evaluations and interventions used in your setting:  FORMTEXT Students should have an understanding of formentioined evaluation processes; Students should be motivated to learn and do independent study.   Target caseload/ productivity for fieldwork students:Documentation: Frequency/ Format (briefly describe) :Productivity % per 40 hour work week:  FORMTEXT 90% Caseload expectation at end of FW:  FORMTEXT 6 clients Productivity % per 8 hour day:  FORMTEXT 90% # Groups per day expectation at end of FW:  FORMTEXT       FORMCHECKBOX  Hand-written documentation:  FORMTEXT SOAP  FORMCHECKBOX  Computerized Medical Records:  FORMTEXT       Time frame requirements to complete documentation:  FORMTEXT daily Administrative/ Management duties or responsibilities of the OT/ OTA student:Student Assignments. Students will be expected to successfully complete: FORMCHECKBOX  Schedule own clients  FORMCHECKBOX  Supervision of others (Level I students, aides, OTA, volunteers)  FORMCHECKBOX  Budgeting  FORMCHECKBOX  Procuring supplies (shopping for cooking groups, client/ intervention related items)  FORMCHECKBOX  Participating in supply or environmental maintenance  FORMCHECKBOX  Other:  FORMTEXT       FORMCHECKBOX  Research/ EBP/ Literature review  FORMCHECKBOX  In-service  FORMCHECKBOX  Case study  FORMCHECKBOX  Participate in in-services/ grand rounds  FORMCHECKBOX  Fieldwork Project ( describe): FORMTEXT        FORMCHECKBOX  Field visits/ rotations to other areas of service  FORMCHECKBOX  Observation of other units/ disciplines  FORMCHECKBOX  Other assignments (please list): FORMTEXT treatment plans/activity analysis Student work schedule & outside study expected:OtherDescribe level of structure for student?Describe level of supervisory support for student?Schedule hrs/ week/ day:  FORMTEXT minimum 40 hours/ weekRoom provided  FORMCHECKBOX yes  FORMCHECKBOX no FORMCHECKBOX  High FORMCHECKBOX  HighDo students work weekends?  FORMCHECKBOX yes  FORMCHECKBOX noMeals  FORMCHECKBOX yes  FORMCHECKBOX no FORMCHECKBOX  Moderate FORMCHECKBOX  ModerateDo students work evenings?  FORMCHECKBOX yes  FORMCHECKBOX noStipend amount:  FORMTEXT 0 FORMCHECKBOX  Low FORMCHECKBOX  LowDescribe the FW environment/ atmosphere for student learning:  FORMTEXT Busy clinic, however supportive experieinced staff Describe public transportation available:  FORMTEXT If arrive by train (Point Pleasant station), will need to take a taxi to transport to hospital. Limited bus service   ACOTE Standards Documentation for Fieldwork (may be completed by AFWC interview of FW Educator) The fieldwork agency must be in compliance with standards by external review bodies. Please identify external review agencies involved with this FW setting and year of accreditation (JCAHO, CARF, Department of Health, etc.). ACOTE on-site review Name of Agency for External Review:  FORMTEXT JCAHO, CARF Year of most recent review:  FORMTEXT 2014 Summary of outcomes of OT Department review:  FORMTEXT       Describe the fieldwork site agency stated mission or purpose (can be attached). ACOTE Standards B.10.1, B.10.2, B.10.3, B.10.4, B.10.14, B.10.15  FORMTEXT "To deliver safe care and the best patient experience in a healing environment to help individuals with disability attain optimal function and advocate for them in the communities we serve." OT Curriculum Design integrated with Fieldwork Site (insert key OT academic curricular themes here): ACOTE Standards B.10.1, B.10.2, B.10.3, B.10.4, B.10.11, B.10.15 How are occupation-based needs evaluated and addressed in your OT program? How do you incorporate the clients meaningful doing in this setting?  FORMTEXT This is done through interview of patient and/or family at time of admission. The treatment plan should be a reflection of areas discussed during the evaluation. Describe how you seek to include client-centered OT practice? How do clients participate in goal setting and intervention activities?  FORMTEXT Client/ Family goals are discussed during the evaluation and incorporated into the treatment plan. Also, the client's activities and funtioning prior to hospitalization are discussed and included in the treatment planning process. Team goals are addressed at conferences.  Describe how psychosocial factors influence engagement in occupational therapy services?  FORMTEXT Greatly important in evaluation, treatment planning, and goal planning. Describe how you address clients community-based needs in your setting?  FORMTEXT Addressed in evaluation, treatment and goal planning;  How do you incorporate evidence-based practice into interventions and decision-making? Are FW students encouraged to provide evidence for their practice? ACOTE Standards B.10.1, B.10.3, B.10.4, B.10.11, B.10.15  FORMTEXT Current staff attend continuing education and independent learning, and incorporate into treatment. During the fieldwork experience, it is expected that the student will improve their clinical reasoning skills by use of evidence based practice.  Please describe FW Program & how students fit into the program. Describe the progression of student supervision from novice to entry-level practitioner using direct supervision, co-treatment, monitoring, as well as regular formal and informal supervisory meetings. Describe the fieldwork objectives, weekly fieldwork expectations, and record keeping of supervisory sessions conducted with student. Please mail a copy of the FW student objectives, weekly expectations for the Level II FW placement, dress code, and copy of entry-level job description with essential job functions to the AFWC. ACOTE Standards B10.2, B.10.3, B.10.5, B.10.7, B.10.13, B.10.19, B.10.20, b.10.21  FORMTEXT copy will be mailed to student prior to beginning of fieldwork Please describe the background of supervisors (please attach list of practitioners who are FW Educators including academic program, degree, years of experience since initial certification, years of experience supervising students) ACOTE Standards B.7.10, B10.12, B.10.17 (provide a template)  FORMTEXT see attached Describe the training provided for OT staff for effective supervision of students (check all that apply). ACOTE Standards B.7.10, B.10.1, B.10.3, B.10.12,B.10.13, B.10.17, B.10.18, B.10.19, B.10.20, B.10.21  FORMTEXT        FORMCHECKBOX  Supervisory models  FORMTEXT        FORMCHECKBOX  Tra-.1Q]   ) 4 ; R Z r s - .    # P e  ! " ( , P U V l øh9m5@CJOJQJaJh h OJQJh\h OJQJh\h 5OJQJh\5@CJOJQJaJ#hBh\5@CJOJQJaJh 5@CJOJQJaJ7-. 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FORMTEXT        FORMCHECKBOX  Reflective practice  FORMTEXT       Comments:  FORMTEXT       Please describe the process for record keeping supervisory sessions with a student, and the student orientation process to the agency, OT services and the fieldwork experience. ACOTE Standards B.7.10, B.10.1, B.10.3, B.10.12, B.10.13, B.10.17, B.10.18, B.10.19, B.10.20, B.10.21  FORMTEXT Student expected to keep daily log; Supervisor to maintain formal supervision meetings with identified growth and areas to improve; Informal meetings may be documented; When needed, learning contracts will be used Supervisory patternsDescription (respond to all that apply)  FORMCHECKBOX  1:1 Supervision Model:  FORMTEXT        FORMCHECKBOX  Multiple students supervised by one supervisor:  FORMTEXT        FORMCHECKBOX  Collaborative Supervision Model:  FORMTEXT        FORMCHECKBOX  Multiple supervisors share supervision of one student, # supervisors per student:  FORMTEXT 2  FORMCHECKBOX  Non-OT supervisors:  FORMTEXT       Describe funding and reimbursement sources and their impact on student supervision. ACOTE Standards B.10.3, B.10.5, B.10.7, B,10.14, B.10.17, B.10.19  FORMTEXT Funding resources include Medicare, Medicaid, workers compensation, idemnity plans, HMO's PPO's and other commericail third party payers. The stuedent will experience how these reimbursement sources are a part of the treatment plan and goals . Status/Tracking Information Sent to Facility To be used by OT Academic Program ACOTE Standards B.10.4, B.10.8, B.10.9, B.10.10 Date:  FORMTEXT       Which Documentation Does The Fieldwork Site Need?  FORMCHECKBOX  A Fieldwork Agreement/ Contract?  FORMTEXT       OR  FORMCHECKBOX  A Memorandum of Understanding?  FORMTEXT       Which FW Agreement will be used:  FORMCHECKBOX  OT Academic Program Fieldwork Agreement  FORMCHECKBOX  Fieldwork Site Agreement/ Contract Title of Parent Corporation (if different from facility name):  FORMTEXT JFK Medical Center Type of Business Organization (Corporation, partnership, sole proprietor, etc.):  FORMTEXT affiliate State of Incorporation:  FORMTEXT NJ Fieldwork Site agreement negotiator:  FORMTEXT Shelley Levin Phone:  FORMTEXT 732-321-7737 Email:  FORMTEXT qqqqqqqqqqqqqqrrrr r$r&rBrDrFrHrnrprrrڶ~qq]ڶGq+j֢h-hoCJOJQJUaJ'j^h8hWcCJOJQJUh8h7CJOJQJ+jh-hoCJOJQJUaJh8h7CJOJQJaJ%jh8h7CJOJQJUaJh8h7CJOJQJ,jh8h7CJOJQJUmHnHu!jh8h7CJOJQJU'jnh8hWcCJOJQJUrrrrrrrrrrrrrrrttttttηΪηΪzlWGh8h76CJOJQJaJ(jh8h76CJOJQJUaJh8h76CJ OJQJh8hX6CJ OJQJh8h76CJ OJQJ'jƣh8hWcCJOJQJUh8h7CJOJQJ,jh8h7CJOJQJUmHnHu!jh8h7CJOJQJU'jNh8hWcCJOJQJUh8h7CJOJQJrrrrkuluuvvHw0xxxzzz d,*$@&gd3 & F d,*$gdwe h*$^hgdK hd,*$^hgdwe & F7$8$H$gd7 0h*$^hgdK h7$8$H$^hgd n 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00d$d%d&d'd*$NOPQ^`0gdjG2 0$ d$d%d&d'd*$@&NOPQgdjG0 0d$d%d&d'd*$@&NOPQgdjGŻߠ߂uŻguߠSQU'j|h8h'CJOJQJUh8hQ5CJOJQJh8hQCJOJQJhCJOJQJ'jh8h'CJOJQJUh8hCJOJQJh8h5CJOJQJhjGCJOJQJh8h nCJOJQJh8hCJOJQJ!jh8hCJOJQJUhCJOJQJmHnHu      Address (if different from facility): Street:  FORMTEXT 65 James Street City:  FORMTEXT Edison  State:  FORMTEXT NJ Zip:  FORMTEXT 08818 Name of student:  FORMTEXT       Potential start date for fieldwork:  FORMTEXT       Any notation or changes that you want to include in the initial contact letter:  FORMTEXT       Information Status:  FORMCHECKBOX  New general facility letter sent:  FORMTEXT        FORMCHECKBOX  Level I Information Packet sent:  FORMTEXT        FORMCHECKBOX  Level II Information Packet sent:  FORMTEXT        FORMCHECKBOX  Mail contract with intro letter (sent):  FORMTEXT        FORMCHECKBOX  Confirmation sent:  FORMTEXT        FORMCHECKBOX  Model Behavioral Objectives:  FORMTEXT        FORMCHECKBOX  Week-by-Week Outline: FORMTEXT        FORMCHECKBOX  Other Information:  FORMTEXT        FORMCHECKBOX  Database entry:  FORMTEXT        FORMCHECKBOX  Facility Information:  FORMTEXT        FORMCHECKBOX  Student fieldwork information:  FORMTEXT        FORMCHECKBOX  Make facility folder:  FORMTEXT        FORMCHECKBOX  Print facility sheet:  FORMTEXT       Revised  DATE \@ "M/d/yyyy" 6/8/2015    PAGE    Zfhjl̠ΠРޠ˽˰ذ؅vذlذXvذذ'jhh8h'CJOJQJUhjGCJOJQJhFcCJOJQJmHnHuhnCJOJQJ'jh8h'CJOJQJUh8hXCJOJQJh8hCJOJQJh8h5CJOJQJh8hCJOJQJ!jh8hCJOJQJU,jh8hCJOJQJUmHnHu   468BDHjlòÞtatKa3a/jh8hX5CJOJQJUmHnHu*j̱h8hWc5CJOJQJU$jh8hX5CJOJQJUh8hX5CJOJQJh8hCJOJQJhnCJOJQJmHnHu'jTh8hWcCJOJQJU!jh8hXCJOJQJUh8hXCJOJQJhFcCJOJQJ!jh8hCJOJQJU'jްh8h'CJOJQJUFH΢ТҢpd 0*$@&gd<5. 0<$d%d&d'd*$NOPQgd<5, 0$d%d&d'd*$NOPQgd<5- 0$d%d&d'd*$@&NOPQgd<5 0*$ơȡءڡܡޡʢ̢΢ТҢȻȻk^Qh8hQCJOJQJh8h<5CJOJQJ'jh8h'CJOJQJU,jh8hCJOJQJUmHnHu'jDh8h'CJOJQJU!jh8hCJOJQJUh8hCJOJQJh8hCJOJQJh8hQ5CJOJQJh8h5CJOJQJh8hX5CJOJQJҢPĥLĦ8<ܨVҩ:<@ d,*$/ 0d,$d%d&d'd*$NOPQgd<50 0d,$d%d&d'd*$@&NOPQgd<5 `bdfz|~ 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