Forms for Fieldwork Educators

Required prior to fieldwork

Fieldwork Data Form-The purpose of the Fieldwork Data Form is to facilitate communication between fieldwork sites, fieldwork students, and Samuel Merritt University. The Accreditation Council for Occupational Therapy (ACOTE) requires that a Fieldwork Data Form be completed prior to a student starting fieldwork at a site. Subsequently, this form should be updated annually. For your convenience, you can download the Fieldwork Data Form and email the completed form to Donna Breger Stanton at


Strongly recommended prior to fieldwork

AOTA Self-Assessment Tool for Fieldwork Educator Competency

This is a useful tool for fieldwork educators to evaluate their own abilities in 5 competency areas: practice, education, supervision, evaluation, and administration. This assessment tool encourages self-reflection and helps fieldwork educators to identify competency areas that they want to improve.

Teaching Style Survey - It is recommended that fieldwork educators explore and understand their own teaching styles prior to supervising students. An inventory such as the Grasha-Riechmann Teaching Style Survey may provide helpful insights. As fieldwork educators gain increased awareness of their own teaching styles, they can more effectively adapt to students' different learning needs.

During Level I Fieldwork

Level I Fieldwork Evaluation is completed by the Fieldwork Educator and reviewed with the student. Please forward a copy of the completed evaluation form to LizKleine, Academic Fieldwork Coordinator, Level I at 450-30th Street, 4th Floor, Oakland, CA 94609. FAX 510-869-6951 or email:

During Level II Fieldwork

Fieldwork Experience Assessment Tool (FEAT) is a tool to promote communication and problem solving between the student and the Fieldwork Educator throughout the fieldwork experience. The FEAT examines 3 key aspects of fieldwork: the fieldwork environment, the Fieldwork Educator, and the student.

Level II Fieldwork, Student Feedback Regarding Fieldwork Supervision Process
At Week 3, this form is completed by the student to reflect on how well the fieldwork experience is meeting his/her learning needs. The student's completed form is shared with the Fieldwork Educator in order to identify any adjustment that can be made to improve the student's comfort level and learning experiences.

Level II Fieldwork, 4 Week and 8 Week Evaluation
This form is completed separately by both the student and the Fieldwork Educator and then reviewed together to promote ongoing feedback and communication over the course of fieldwork. Please provide a copy of all completed forms to the Level II Academic Fieldwork Coordinator, Donna Breger Stanton.

Level II Fieldwork, AOTA Fieldwork Performance Evaluation for the Occupational Therapy Student
The AOTA evaluation forms will be provided to the Fieldwork Educator by each student upon arrival at the fieldwork site. Please complete this evaluation at Week 6 (midterm) and Week 12 (final) and share the results with the student. A sample copy of this form is provided in the Appendix of .  Due to copyright issues, it is not possible to add a link to this document.  If needed, students are able to purchase an additional copy at the university bookstore.

Upon the student's completion of fieldwork, please send an original copy of the evaluation form within 2 weeks to Donna Breger Stanton, Occupational Therapy Department, Samuel Merritt University, 450-30th Street, Oakland, CA 94609. Please note that a student cannot receive a grade for fieldwork until this final evaluation has been received; your timeliness in returning the form is greatly appreciated.

Level II Fieldwork, Student Evaluation of Fieldwork Experience (SEFWE)
is completed by the student and reviewed with the Fieldwork Educator at Week 12. A copy of this form is provided to the students directly in packets provided for each of the students going out on fieldwork.  In addition, the students now can access the SEFWE via a link provided to them on their Learning Management System, Canvas to complete the form on Survey Monkey, or the paper copy is posted for students to download for use to evaluate the site and discuss with their fieldwork educators.

Learning Contracts are useful when specific professional or clinical behaviors require improvement. The learning contract is an agreement that is developed collaboratively by the student and the Fieldwork Educator. A sample learning contract and a learning contract template are provided.

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