Winthrop University
Department of Social Work
Student Interview Form
To be completed by student
Student’s Name:
__________________________________________
Agency Interviewed:
__________________________________________
Date Interviewed:
__________________________________________
Person Interviewed with:
__________________________________________
____________ I accept this agency as my field placement.
____________ I do not accept this agency as my field placement.
If you do not accept this agency, briefly explain why:
____________________________________
Student’s Signature
Please fax/mail or email completed form to:
Field Office
Department of Social Work
Winthrop University
Rock Hill, SC 29733
Fax: 803-323-3386
________________________
Date