Winston-Salem State University

Fieldwork Forms

Fieldwork Requirements Upon Admission
Hepatitis Declination Form
Wellness Center Health Information Requirements Packet
WFBMC Nonemployee Confidential Agreement
WFUBMC Registration/Non-EE form for Students
Student Evaluation of Level I Fieldwork Experience
Student Evaluation of the Fieldwork Experience (SEFWE)
Fieldwork Educators
Fieldwork Data Form



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

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

WFUBMC 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 Gayle Bullock AFWC Assistant, bullockga@wssu.eduby June 1.

Wake Forest Baptist Medical Center Nonemployee Confidential Agreement

WFUBMC 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 University Baptist Medical Center Non-EE Form for Students

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

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 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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