Rev 2015
Winthrop University
Department of Social Work
Application for MSW Field Instruction
**Please type or print clearly.
Name :
WU E-mail Address:
Address:
Do you have a valid Driver’s License?
Do you have transportation available?
Expected date of graduation:
CWID:
Primary Phone Number:
_____Yes _____ No
_____ Yes _____ No
If yes, which state: ________
Advisor:
GPA:
Do you anticipate being employed while in field? _____Yes _____ No
If so, how many hours per week do you anticipate working? _____________
If yes, attach a brief description of how you plan to balance the requirements of field placement and
course work with the requirements of your employment.
Do you require any special accommodations in your field placement?
If yes, please explain:
_____ Yes _____ No
Have you ever been convicted of a crime other than a minor traffic offense? _____ Yes _____ No
If yes, please explain:
Some field agencies require that students meet additional requirements prior to admitting them to the agency for
placement. These might include a criminal background check, immunization screenings, drug screenings,
employee/volunteer training classes etc. It is the student’s responsibility to complete, and if needed, pay for
these additional requirements. Please note that the field office cannot guarantee a field placement if you are
unable to successfully pass agency drug screenings and criminal background checks. Please openly and
honestly discuss any concerns you may have regarding these issues with the Field Director.
Each student applying for a field placement is required to turn in the following information prior to their
field appointment:
1. Completed application for field
2. Current resume
3. Signed Social Work Termination Policy
4. Essay – typed, double-spaced and not to exceed three pages
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Rev 2015
Content of the essay should:
1. Describe any special skills you possess; such as interviewing, problem solving, crisis intervention etc.
2. Discuss any personal attributes or characteristics that you feel would be assets to you as a social worker.
3. Discuss any limitations or weaknesses that you feel need to be addressed in field work.
4. Summarize the salient aspects of your volunteer or paid work experiences and class experiences.
5. Identify the types of learning experiences that you want to learn from your field placement.
6. Include any additional information that you think would be helpful in making the decision regarding
your placement.
List in order of preference the type of agency in which you are most interested.
1. _____________________________________________________________________________________
2. _____________________________________________________________________________________
3. _____________________________________________________________________________________
FIELD INSTRUCTION RELEASE OF INFORMATION FORM
I hereby authorize the Field Director for the Department of Social Work to release and share with any potential
and/or assigned field instructor, information from my academic record that could assist me in the successful
selection and completion of the field experience. This release is granted until I complete my field experience.
Signature
Date
ACKNOWLEDGEMENT OF RISK IN FIELD
I have read the Acknowledgement of Risk in Field document and understand that the field practicum may
present some risks. I also understand that prudent choices and exercising caution can minimize these risks. I
further recognize that it is my responsibility to become informed of agency policy and practices regarding safety
in the field.
Signature
Date
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