ST. CATHERINE UNIVERSITY AND UNIVERSITY OF ST. THOMAS
SCHOOL OF SOCIAL WORK
FIELD INSTRUCTOR AGREEMENT FORM
Cover Sheet
Field Instructor Name: ___________________________________________________________
Student name (if known): ________________________________________________________
I intend to supervise (check all that apply):
BSW student(s) _______
MSW student(s) ______
Please complete and sign the form, and return the form and this cover sheet by mail or fax to:
School of Social Work
St. Catherine University and the University of St. Thomas
2004 Randolph Ave., Mail: F-15
Saint Paul, MN 55105
Office Fax: 651-690-8821
(You may also email a scanned version, with your signature, to: Rachel Miller, ramiller@stkate.edu)
For Office Use Only:
Reviewed by Field Director/Coordinator (initials): ________________
Eligible as Field Instructor for: BSW _____
MSW Foundation ______
Comments:
Entered in IPT: ________________(entry date)
Field Instructor Agreement Form, Revised April 2014
MSW Clinical ______
ST. CATHERINE UNIVERSITY AND UNIVERSITY OF ST. THOMAS
SCHOOL OF SOCIAL WORK
FIELD INSTRUCTOR AGREEMENT FORM
NAME: _______________________________________________
DATE: ______
AGENCY NAME: ________________________________________________________
AGENCY ADDRESS:______________________________________________________
(Street)
(City/State)
(Zip)
OFFICE PHONE: _________________________ CELL PHONE: ___________________
JOB TITLE: _________________________ E-MAIL ADDRESS: _________________
LICENSED SOCIAL WORKER?
Level of Licensure in MN:
Level of Licensure in other state:
_____Yes
_____License #
_____Pending
_____No
_____LSW
_____LGSW
_____LISW
_____LICSW
__________State
__________Level
Your signature affirms your agreement to provide direct supervision for the social work students
placed in your agency and to fulfill the following responsibilities:
 Participate in the Field Instructor Orientation
o BSW: held in August for seniors and October for juniors
o MSW: held in August for academic year placements, and May for summer block
placements
 Participate in seminars, workshops, and other special activities arranged by the Directors of
BSW/MSW Field Education
 Select appropriate assignments and with the student create a field agreement (BSW) or field
education contract (MSW) which reflects pathways to acquire the core competencies.
 Provide for the student an orientation to agency and job/task.
 Provide regularly scheduled formal supervision per the requirements of the program (BSW or
MSW).
 Provide on-going supervision and evaluation of your student throughout the placement.
 Participate in meetings with the student and faculty liaison throughout the field placement,
usually two per school year.
 Complete and submit requested materials to the field education program (e.g., field instructor
agreement form, student evaluations, etc.), in electronic or hard copy formats, as required.
 Work collaboratively with the field faculty liaison and student to identify both strengths and
areas for professional growth and maximize the student’s potential for success. Notify the field
faculty liaison of any problems or questions as soon as they become evident.
______________________________________________________
(Signature)
Field Instructor Agreement Form, Revised April 2014
____________________
(Date)
UNDERGRADUATE COLLEGE EXPERIENCE
NAME OF COLLEGE _______________________________________
_______
LOCATION: _______________________________________________
(City, State)
MAJOR: __________
_____
MINOR AREA OF EMPHASIS: _______ ________
YEAR OF GRADUATION: __________
_____ DEGREE: _______
________
GRADUATE EXPERIENCE
NAME OF COLLEGE: _____________________________________________
LOCATION: ______________________________________________
_
(City, State)
AREA OF CONCENTRATION: _______________
YEAR OF GRADUATION: __________
_____ DEGREE: _______
________
PROFESSIONAL WORK EXPERIENCE (LIST CURRENT POSITION FIRST)
AGENCY NAME: __________
___
AGENCY SUPERVISOR: ____________
AGENCY LOCATION: ______________________________________________
(Street)
(City/State)
JOB TITLE: _______________
Check one:
FULL-TIME
_
(Zip)
PART-TIME
DATES WORKED AT THE AGENCY: FROM: _______________ TO: _______________
Month and Year
Month and Year
JOB DESCRIPTION:
______________________________________________________________________________
______________________________________________________________________
AGENCY NAME: __________
___
AGENCY SUPERVISOR: ____________
AGENCY LOCATION: ______________________________________________
(Street)
(City/State)
JOB TITLE: _______________
Check one:
FULL-TIME
_
(Zip)
PART-TIME
DATES WORKED AT THE AGENCY: FROM: _______________ TO: _______________
Month and Year
Month and Year
JOB DESCRIPTION:
______________________________________________________________________________
______________________________________________________________________________
Field Instructor Agreement Form, Revised April 2014