EMPLOYER BASED FIELD PRACTICUM PROPOSAL
This form is to be completed by the student requesting to use his/her place of employment as a
placement site for their Foundation Practicum only.
Approved placement sites must meet the following minimum criteria:
1. Afford learning opportunities that meet the learning objectives specified in the Foundation
practicum.
2. Value the student’s educational experience by making programmatic accommodations to meet
the student’s learning needs as necessary.
3. Assign a qualified MSW field instructor who is not the student’s work supervisor and who meets
the criteria as specified in the most current UNC-CH, School of Social Work, Field Education
Manual.
Student Name
____________________________________________________
Program (Select one)
Foundation
Concentration Direct Practice
Concentration MCPP
Agency Name
____________________________________________________
Agency Address
____________________________________________________
____________________________________________________
Web Address
____________________________________________________
I. Current Duties:
A.
Current work supervisor:
Name _______________________________________________
Title _______________________________________________
Telephone # __________________________________________
Email Address _________________________________________
Unit Name_____________________________________________
B.
Briefly describe the duties and responsibilities of the paid position, including
title/position name, the population served and interventions utilized (attach a job
description).
_____________________________________________________
_____________________________________________________
_____________________________________________________
C.
How many years total have you been employed by this organization? _____
D.
How long have you been in your current position? _____
E.
Have you satisfied your probationary period? _____ yes ____ no
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EMPLOYER BASED FIELD PRACTICUM PROPOSAL
F.
If applicable, describe the duties and responsibilities of past positions you have held in
this organization.
_____________________________________________________
_____________________________________________________
II. Proposed Placement:
A.
Briefly describe your proposed field placement (population to be served, social work
role, assessment and intervention models to be learned and utilized).
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
B.
Proposed Field Instructor:
Name: ________________________________________________
Degree/Institution:______________________________________
Address: ______________________________________________
Telephone Number: _____________________________________
Email Address: _________________________________________
Proposed Task Supervisor (if applicable):
Name: ________________________________________________
Degree/Institution:______________________________________
Address: ______________________________________________
Telephone Number: _____________________________________
Email Address: _________________________________________
C.
Describe how your proposed placement will differ from your regular job.
Will you: (Check all that apply)
____ be assigned a new unit;
____ work with a different client population;
____ receive field instruction from someone other than your work supervisor;
____ use different social work intervention methods
Other:________________________________________________
_____________________________________________________
_____________________________________________________
D.
Identify any learning activities that are not included in your job description.
_____________________________________________________
_____________________________________________________
_____________________________________________________
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EMPLOYER BASED FIELD PRACTICUM PROPOSAL
E.
Identify any employment responsibilities that will not qualify as field placement hours:
_____________________________________________________
_____________________________________________________
_____________________________________________________
F.
For each of the following nine competencies, articulate proposed activities that will
enable you to achieve the assigned learning outcomes:
Competency 1 – Demonstrate Ethical and Professional Behavior
Proposed Learning Activities:
______
Competency 2 – Engage Diversity and Difference in Practice
Proposed Learning Activities:
______
Competency 3 - Advance Human Rights and Social and Economic, and Environmental
Justice
Proposed Learning Activities:
______
Competency 4 – Engage in Practice-informed Research and Research-Informed
Practice
Proposed Learning Activities:
_____________
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EMPLOYER BASED FIELD PRACTICUM PROPOSAL
Competency 5 – Engage in Policy Practice
Proposed Learning Activities:
______
Competency 6 – Engage with Individuals, Families, Groups, Organizations, and
Communities
Proposed Learning Activities:
_______________________________________
Competency 7 – Assess Individuals, Families, Groups, Organizations, and Communities
Proposed Learning Activities:
______
Competency 8 – Intervene with Individuals, Families, Groups, Organizations, and
Communities
Proposed Learning Activities:
______
Competency 9 – Evaluate Practice with Individuals, Families, Groups, Organizations,
and Communities
Proposed Learning Activities:
______
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EMPLOYER BASED FIELD PRACTICUM PROPOSAL
E.
Proposed Work and Field Education Schedule:
Understanding that the student may not have enrolled for classes as of yet, complete
(as much as possible) a time plan as discussed by the student, supervisor, and proposed
field instructor. Be sure that the field hours add up to the required hours per week.
When completing this section, follow this example:
Monday
From: 8:30
To: 5:00
Field Placement
From: 6pm
To: 9pm
Work
DAY
TIME
ACTIVITY
(placement, class,
work, or other)
TIME
ACTIVITY
(placement, class,
work, or other)
Monday
From:
To:
Tuesday
From:
To:
Wednesday
From:
To:
Thursday
From:
To:
Friday
From:
To:
Note any concerns about
allocating sufficient time for the
field placement:
From:
To:
From:
To:
From:
To:
From:
To:
From:
To:
F.
Describe how your regular work assignment will be altered or reduced to accommodate
the student’s role and tasks (e.g. additional hours; caseload or job responsibility
reduction; tasks that will be assumed by other staff; any other measures taken).
G.
Does the Field Education Office have your permission to contact your work supervisor
and your proposed Field Instructor to discuss this proposal?
_______
Yes
______ No
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EMPLOYER BASED FIELD PRACTICUM PROPOSAL
III.
Signatures:
Student:
___________________________ __
Print Name
_______________________ ________
Signature
Date
Field Instructor: __________________________
Print Name
_______________________ ________
Signature
Date
Task Supervisor: __________________________
Print Name
_______________________ ________
Signature
Date
Work Supervisor: __________________________
Print Name
_______________________ ________
Signature
Date
Agency Head: ____________________________
Print Name
_______________________ ________
Signature
Date
Field Faculty: ____________________________
Print Name
_______________________ ________
Signature
Date
Field Director: ____________________________
Print Name
_______________________ ________
Signature
Date
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