Winston-Salem State University

Fieldwork Forms

Fieldwork Requirements Upon Admission
Certified Background Student Instruction Form 
Checklist for Health Requirements Packet
Checklist for Immunization Requirements
Hepatitis Declination Form
HIPPA / FERPA Information for Certified Background
Wellness Center Health Information Requirements Packet
WFBMC Nonemployee Confidential Agreement
WFBMC Registration/Non-EE form for Students
Map to WFBMC
Level I
HIPPA Training & Verification Form
Attestation Form
Bloodborne Pathogens Verification Form
Consent to Disclose Personal/Health Information
Preference Request Form
Level I Fieldwork Student Evaluation
Student Evaluation of Level I Fieldwork Experience
Level II
Preference Request Form A and B
Personal Data Sheet
Student Evaluation of the Fieldwork Experience (SEFWE)
Fieldwork Educators
Fieldwork Data Form 

 


 

Admissions

Certified Background Student Instruction Form

This is a resource for guidance in obtaining an account with CertifiedProfile and placing an order for the criminal background check, sex offender index, and 12 panel drug screening.

Form: Certified Background Student Instruction

Checklist for Health Requirements Packet

  • Complete this form to ensure that you have met all Fieldwork requirements. You may type into this form.
  • Email completed form to the Academic Fieldwork Coordinator Assistant (AFWCA) and copy the Academic Fieldwork Coordinator (AFWC).
Form: Health Requirements Checklist

Checklist for Immunization Requirements

  • Complete this form to ensure that you have met all immunization requirements for Fieldwork courses. you may type into this form.
  • Email completed form to the Academic Fieldwork Coordinator Assistant (AFWCA) and copy the Academic Fieldwork Coordinator (AFWC).
Form: Immunization Requirements Checklist

Hepatitis Declination Form

  • Complete form if you decline to participate in the Hepatitis B vaccine series or Hepatitis B Antibody.
  • Upload form to certifiedbackground.com along with official immunizations record form.
Form: Hepatitis Declination

HIPPA & FERPA Information for Certified Background

This is a resource providing information on your HIPPA and FERPA rights regarding CertifiedBackground.com

Form: HIPPA & FERPA Information for Certified Background

Wellness Center Health Information Requirements Packet

Submit this packet to the Wellness Center at least 30 days prior to arrival on campus to:

WSSU Student Health Services, RM 244
601 Martin Luther King, Jr. Dr.
Winston Salem, 27110

Form: Student Health Information Requirements

WFBMC Nonemployee Confidential Agreement

  • This form is required for obtaining clearance to participate in courses at Wake Forest Baptist Medical Center.
  • Complete this form and submit it to the Academic Fieldwork Coordinator (AFWC) before the Occupational Therapy Department's Orientation Day at: browndp@wssu.edu.

Wake Forest Baptist Medical Center Nonemployee Confidential Agreement

WFBMC Registration/Non-EE Form for Students

  • This form is required for obtaining clearance to participate in courses at Wake Forest Baptist Medical Center.
  • Complete this form and submit it to the Academic Fieldwork Coordinator (AFWC) before the Occupational Therapy Department's Orientation Day at: browndp@wssu.edu.

Wake Forest Baptist Medical Center Non-EE Form for Students

Map to WFBMC

Please refer to this map of Wake Forest Baptist Medical Center for your orientation day.


Level I Tab

HIPPA Training & Verification Form

Complete this form and upload to certifiedbackground.com after completing the HIPPA Training Module in OCC 5104: Fieldwork Level I-Occupation - Due September 30th.

Form: HIPPA Training & Verification

Attestation Form

Complete this Statement of confidentiality and ethical responsibility and upload to Certifiedbackground.com upon completion of HIPPA Training Module in OCC 5104: Fieldwork Level I-Occupation - Due September 30th

Form: Attestation

Bloodborne Pathogens Verification Form

Complete this form and upload to certifiedbackground.com after completing the Bloodborne Pathogens Training in OCC 5104: Fieldwork Level I-Occupation - Due September 30th.

Form: Bloodborne Pathogens Verification

Consent to Disclose Personal/Health Information

This form grants us permission to disclose personal and health information to your fieldwork site.  The form applies for both Level I and Level II experiences.

Preference Request Form

  • This form is for indicating your site preferences for Level I Fieldwork - Adults. This form will be completed during the fourth semester of the OT program.
  • Please submit completed from as a hard copy to the Academic Fieldwork Coordinator (AFWC) or the Academic Fieldwork Coordinator Assistant (AFWCA).
Form: Preference Request Form

Level I Fieldwork Student Evaluation

  • Print out and give to Fieldwork I Educator for final assessment of student performance in Level I Fieldwork experiences.
  • This form is to be completed by Level I Fieldwork Educator or faculty member overseen the Level I fieldwork experience and it is a requirement for receiving your final grade for all four Level I Fieldwork Courses.
Form: Student Evaluation - Level I

Student Evaluation of Level I Fieldwork Experience

  • This form is an evaluation of the student's fieldwork I experience.
  • Complete this form before your final fieldwork assessment meeting with your fieldwork educator or faculty member.
  • Submit a copy to the faculty member overseen the Level I fieldwork experience.
Form: Student Evaluation of Fieldwork -Level I

Level II Tab

Preference Request Form A and B

  • This form is for indicating your site preferences for Level II Fieldwork A and B.
  • Please submit completed from as a hard copy to the Academic Fieldwork Coordinator (AFWC) or the Academic Fieldwork Coordinator Assistant (AFWCA).
Form: Preference Request Form A and B

Personal Data Sheet

This form is to be completed by the student and submitted to the assigned Level II fieldwork educator prior to the start of the fieldwork experience.

Form: Personal Data Sheet

Student Evaluation of the Fieldwork Experience (SEFWE)

  • The SEFWE is an evaluation of the student's fieldwork II educational experience and it is a requirement for obtaining a final grade on each of the Level II fieldwork practicums.  The SEFWE is to be completed by the student upon completion of each Level II fieldwork experience.  Review this form with your fieldwork educator during your final review/evaluation meeting.
  • Provide a copy of the SEFWE to your fieldwork educator and mail it along with the Fieldwork Performance Evaluation for the Occupational Therapy Student in the enveloped provided in the FW packet.
Form: Student Evaluation of the Fieldwork Experience

Fieldwork Educators

Fieldwork Data Form   

Form: Fieldwork Data Form

Winston-Salem State University

601 S. Martin Luther King Jr. Drive

Winston-Salem, NC 27110

Phone: (336) 750-2000



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