CI Questions - Updated

Please provide the following information about your fieldwork supervisor (if more than one, please
indicate whether one is "primary" but provide information for all). This form needs to be
COMPLETE. You do receive credit for it. Make sure this form is typed or is VERY legible.

1. Name of Facility:_____________________________________________________________

2. Address of Facility: ___________________________________________________________

3. Typical Work Schedule You will be following:________________________________________

4. Name and credentials (e.g., OTR/L, COTA/L, OT/L, OTA/L, OTR, COTA, MS, MOT, etc.) -
this will appear on their certificate verifying provision of FW supervision, so please make sure it's
accurate.
a. Primary Supervisor:______________________________________________________

i. Credentials:_____________________________________________________

ii. Number of years in practice:________________________________________

iii. Year of original Certification:_______________________________________

iv. Any Specialty Certification:________________________________________

v. License Number:_________________________________________________

vi. Phone Number:___________________________________________________

vii. Email Address:___________________________________________________

b. Other Supervisor:______________________________________________________

i. Credentials:_____________________________________________________

ii. Number of years in practice:________________________________________

iii. Year of original Certification:_______________________________________

iv. Any Specialty Certification:________________________________________

v. License Number:_________________________________________________

vi. Phone Number:___________________________________________________

vii. Email Address:___________________________________________________

Please provide the following information about your fieldwork site:

1. Number of OT staff (OTR and COTA) employed

______________________________________________________________________________________

______________________________________________________________________________________

2. Primary client population(s) served

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

3. Specialty services provided

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

4. Current OT/OTA jobs open

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________