LAKE AREA
TECHNICAL INSTITUTE
OCCUPATIONAL
THERAPY ASSISTANT PROGRAM
STUDENT
SUPERVISOR GRIEVANCE OF AN OTA STUDENT
(FOR LEVEL I
AND LEVEL II FIELDWORK EXPERIENCES)
To
be completed by the Student Supervisor of the fieldwork facility. Please utilize the back of this page if
needed.
DATE
______________________________________________
NAME
OF FACILITY: _________________________________________________________________________
STUDENT
SUPERVISOR: ______________________________________________________________________
STUDENT:
___________________________________________________________________________________
NATURE
OF GRIEVANCE:
Facility
policy (if any) regarding grievance and action to be taken against the OTA
student:
If
no facility policy exists; administration's or the
student's supervisor recommended action to be taken against the OTA student:
SUPERIVISOR
SIGNATURE ______________________________________________ DATE _______________
STUDENT SIGNATURE __________________________________________________ DATE _______________