REQUEST FOR BSW BLOCK PLACEMENT
University of Montana
School of Social Work
updated 9/14
BLOCK PLACEMENT:
 Students must have a 3.4 UM GPA and demonstrate professional readiness for practicum to request
a block placement.
 Students must submit their request for a block placement the semester prior to the block placement.
Criteria for Block Placements:
 Block placements are only permitted for international or out-of-town placements.
 The practicum plan and memorandum of responsibilities must be filled out and returned to the
practicum office the semester prior to the block placement.
 Students must submit a plan for completing the 450 practicum hours the semester prior to the block
placement.
Date of Application
Name
Address
City
State
Phone
Zip
UM Email
UM G.P.A.
@umontana.edu
Social Work G.P.A.
Requested Practicum Agency
References:
1. (SW Faculty)
Phone
2. (Employment or volunteer supervisor)
Phone
Plan:
Advanced Practice I
____ Semester
Advanced Practice II
_____ Semester
______(year)
______(year)
Proposed schedule of practicum hours:
Date practicum begins
Date 450 practicum hours will be complete
***Please return this form & set up an appointment with the Practicum Coordinator.***
TO BE COMPLETED BY PRACTICUM COORDINATOR
Block Placement Approved or Denied?
Practicum Coordinator Signature
Reasons for Approval / Denial:
(check one)
Approved
Denied