Date Completed
Date completed ________________________
BAYLOR UNIVERSITY SCHOOL OF SOCIAL WORK
FIELD EDUCATION
TASK SUPERVISOR’S INFORMATION SHEET
I.
Contact Information
Name
Agency
Title
Office Phone
Fax
Cell
Email
Work Address
Home Address
Home Phone
Social Security # or Baylor ID #
(Social Security # is provided to Human Resources in order to receive benefits and then replaced
with a Baylor ID#. It is not required to supervise. If you are a current Baylor student, faculty/staff
or a Baylor alumni, list your Baylor ID# in place of SS#)
Professional License
Professional Memberships
II.
Education
Degree
School
Year Graduated
III.
Work Experience (start with most recent experience)
Type of Work
IV.
Employer
Length of
Employment
What experience (if any) have you had supervising students?
Levels
Schools
Dates
V.
Special interests or life experiences that might be helpful in selecting a student for field
placement with you:
VI.
What student characteristics seem to be important with regard to the student getting the most
out of your particular placement? Or for what kind of student does your placement really offer
the most?
VII.
As a task supervisor, you will be working with a social work field specialist or social work field
instructor who will meet with the student regularly for social work supervision and for
evaluation. What information will help the field instructor/specialist to work closely and
effectively with you?
Previous experience supervising students:
Please attach resume
Signature
Rev. 01/25/12
Date