C.1.8 FWE Verification Form
C.1.8 FWE Verification Form
Today's Date
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MM
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DD
YYYY
Educator Name
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First
Last
Facility Name & Location
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Job title
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e.g. OT/L, OTR/L, etc.
Current State Where Licensed *Put n/a, if not applicable
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License # *Put n/a, if not applicable
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Educator's Email Address
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Years of experience in professional field
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Number of years you have supervised UCA OT fieldwork students
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List any specialties, certifications, (e.g. mental health, geriatrics, etc.).
Spec/Cert 1.
Spec/Cert 2.
Spec/Cert 3.
Spec/Cert 4.
Spec/Cert 5.
Other Memberships, please list:
Describe your teaching approach and style of supervision.
Do you feel adequately prepared to supervise a fieldwork student? Please indicate: Yes or No
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If no, may we contact you via email regarding what resources may be needed for support? Please indicate: Yes or No
Please indicate that you have received and reviewed the course objectives in your email packet.
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I have read the course objectives.
I have not received the course objectives.
Please indicate your agreement with and intention to collaborate with UCA OT in meeting the course objectives for this fieldwork experience. *Please check all that apply.
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I agree with the course objectives.
I do not agree with the course objectives.
I would like to discuss the objectives with the Fieldwork Coordinator.
Resume, CV, or any other professional summary may be uploaded.
