Last Name Email Field Instructor Application-­‐MSW Program First Name Middle Initial Date Cell MSW Degree Date MSW Institution Professional Credentials/Licensing Licensing State Current Agency Information Agency Name Address Email Phone Fax Do you intend to be a field instructor at your agency or an off-­‐site field instructor or both? How many students are you willing to provide supervision to? (Field Instructors may supervise one to three students). Supervision Please check all of the areas in which you are best prepared to provide supervision. ☐Addictions ☐Latino Children, Youth, Families, & Communities ☐Administration ☐Legal S ervices ☐Advocacy ☐Legislation ☐Aging/Gerontology ☐Management ☐AIDS/HIV ☐Medical Social Work ☐Behavior Modification ☐Mental Health, Substance Abuse ☐Case M anagement ☐Military/Veterans ☐Child Welfare ☐Negotiation/Mediation ☐Children, Youth, & Families ☐Policy Analysis ☐Community Work ☐Poverty Issues ☐Criminal Justice ☐Program Planning/Development ☐Crisis Intervention/Management ☐Program/Policy Evaluation ☐Development Disabilities ☐Psychiatric Services ☐Domestic Violence ☐School Social Work ☐Economic Development ☐Sexual Abuse ☐Grant Writing ☐Trauma ☐Group Work ☐Work with Volunteers ☐Health ☐Youth Services ☐Homelessness _______________________________Other ☐Hospice/Death/Dying Issues ☐Immigration & Refugee Please provide further description about your areas of expertise and how they will enhance your ability to provide field instruction to our students.
What do you hope to contribute and gain by being a field instructor? Your signature below indicates that: • You agree to provide at least 1 hour per week of supervision to MSW practicum students • You will orient the student to the agency and provide safety training • You will work with the student to complete the education contract • You will facilitate learning activities appropriate for graduate level social work • You have reviewed the Field Manual and understand and agree to fulfill the field instructor roles and responsibilities as indicated in the manual • You will evaluate the student’s performance at mid-­‐year and at the conclusion of the practicum • You will review the evaluation of student performance with the student • You agree to abide by the NASW code of ethics Signature _______________________________ Please email or fax this form along with your current resume to Rachel Jensen, the Director of Field Placement at: jensenr@pacificu.edu 541-­‐485-­‐7015 (fax)