Appendix I: Field Forms - Overview
FORMS
8/2013
1. BSW/MSW FIELD WORK APPLICATION FORM: Student fills
this out prior to their meeting with Field Coordinator in preparation
for placement in field.
2. STUDENT FIELD AGREEMENT WITH AGENCY: Student brings
this form to the agency upon acceptance of practicum placement.
Formal record of agreement with field instructor to regarding work
hours and contact information. Placed in student file
3. FIELD WORK AGREEMENT IN STUDENT’S PLACE OF
EMPLOYMENT: Documents how student duties and field
instructor for their field practicum differ from employment.
4. PORTFOLIO OUTLINE: Student maintains a portfolio and has it
ready for review at midterm and final.
5. STUDENT DOCUMENT TRACKING FORM - This is a check list
with dates. Students are required to keep track of all of their
assignments, seminars attended, hours in the field on a summary
sheet to be added to their Portfolio.
6. WEEKLY SUPERVISORY MEETING AGENDA and TIME AND
ACTIVITIES REPORT (one per week) This is a form to help the
student keep track of what they are doing each day and the hours
they are in the field and the long term goals in the supervision. It is
essential that the Field Instructor comment on this form and sign it.
8. BIOPSYCHOSOCIAL ASSESSMENT MSW 552 or
CASE PRESENTATION OUTLINE MSW 555: Student prepares
an assessment or case to present in their seminar.
9. AGENCY PRESENTATION OUTLINE MSW 551 and 554:
Student prepares a presentation on their practicum agency.
10. PROCESS RECORDING: TWO PER SEMESTER This is a vital
form of evaluation the students’ progress in competency 10 –
engagement, assessment, intervention, and evaluation.
11. CHANGE OF PLACEMENT REQUEST: Students and Field
Instructors cannot terminate a placement without providing
reasons for the request and an explanation of attempts to
address issues.
12. BSW/MSW STUDENT EVALUATION OF FIELD AGENCY,
FIELD INSTRUCTOR & LIAISON: Student should fill this out at
the end of every semester.
(Form 2013)
1
PERSON RESPONSIBLE
Student
Referred To
Student, Field Instructor and Field
Coordinator
Student, Field Instructor, Employment
Supervisor and Field Coordinator.
Student
Student – signed by Field Liaison end of
semester
Student and Field Instructor needs to
comment and sign (at supervisory
meeting)
Student
Student
Student - Field Instructor comments.
Given to Field Liaison
Completed by student, Field Instructor
and Field Liaison
Student
NMSU SCHOOL OF SOCIAL WORK
BSW/ MSW FIELD WORK APPLICATION
Referred To:
Name: __________________________________ Date of application: ________
Student Banner ID: _____________ Academic Advisor: _______________
Dates of Placement – August _______to May ________
I AM ENTERING THE FIELD AT THE FOLLOWING PROGRAM LEVEL:
□ BSW STUDENT SENIOR YEAR:
MSW SECOND YEAR FIELD PLACEMENT:
□ Full-time MSW 2nd Year Student
MSW FIRST YEAR FIELD PLACEMENT:
□ Full-time MSW 1st Year Student Entering Field
for the First Time
□ Part-time MSW Student (2nd year) Entering
Field for the First Time
□ Part-time MSW Student (3rd year)
□ Full-time MSW Advanced Standing
□ Part-time MSW Adv. Standing Student (2nd
year)
ARE YOU RECEIVING A CYFD STIPEND? ______ (yes) _________ (no)
Local Address:
_________________________________________________________________
_____________________________________ ____________ ______________
(City)
(State)
(Zip)
Permanent Address:
_________________________________________________________________
________________________________ _________________ ______________
(City)
(State)
(Zip)
Telephone (____) ________________ (____)________________
(Home)
(Cell phone)
(____) ______________
(Work)
E-mail ___________________________________
MOST RECENT HUMAN SERVICE RELATED EXPERIENCE:
1. Agency Name: _______________________________ Job title: _______________ Full time __Part time __
Name of your Supervisor: ___________________________
Length of Service: __________________
Description of the work you did at this agency: _____________________________________________
_____________________________________________________________________________
2. Agency Name: _______________________________ Job title: _______________ Full time __Part time __
Name of your Supervisor: ___________________________
Length of Service: __________________
Description of the work you did at this agency: _______________________________________________
_____________________________________________________________________________________
(Form 2013)
2
NMSU SCHOOL OF SOCIAL WORK BSW/ MSW FIELD WORK APPLICATION pg 2
YOU WILL HAVE TWO SEMESTERS IN YOUR FIELD PLACEMENT. WHAT WOULD YOU LIKE TO LEARN THIS
YEAR? BE SPECIFIC. What are the social work skills, roles, and levels of service in which you need more
practice experience?
WHAT KIND OF SOCIAL WORK JOB DO YOU SEE YOURSELF HAVING IN FIVE YEARS?
PLACE A CHECK MARK NEXT TO THE TYPES OF PROGRAMS YOU WOULD LIKE CONSIDER AS PLACEMENTS.





Children and family services
Mental Health
Medical
Health
Poverty advocacy










Criminal Justice
Schools
Rehabilitation
Public Welfare
Military Services
Substance abuse
Residential treatment
Developmental disability
Elderly
Other
Feel free to provide contact names and phone numbers if you have a particular interest in an agency. Please note
that your choices are given serious consideration, but your field placement setting is determined by agency
availability and fit.
1.______________________________________________________________________
2.______________________________________________________________________
MEANS OF TRANSPORTATION:
You will be required to travel to your field site and in the surrounding area. Do you have a means of
transportation? Yes______ No______
If no, how do you plan to meet these requirements? _______________________________________
OTHER INFORMATION REGARDING YOUR FIELD WORK PREFERENCES:
In what geographic area would you prefer your field work to be? (It may be necessary to travel up to 50
miles from your home)
□ Las Cruces
□ Albuquerque
□
□
□
□
El Paso
Alamogordo
Grants - Gallup
Other ___________
ARE YOU BILINGUAL? □ Yes □ No
If yes, list the language(s) you speak in addition to English:
________________________________________________________________________
Rate your abilities for the additional language(s) you listed using the following criteria.
P = Proficient (exceptionally capable) A = Able
D=Developing
B=Beginner
______ Reading _______ Writing ________ Speaking _____Translating ______ Interpreting
DID YOU APPLY FOR THE HISPANIC CHILD WELFARE STIPEND? ______ (yes) ______ (no)
OTHER INFORMATION: Do you have any special needs, limitations, and/or recommendations that need to be
considered in field agency selection? Please explain. ___________________________________________
________________________________________________________________________________________
Student name___________________________________________
(Form 2013)
3
Date
___________________
NMSU SCHOOL OF SOCIAL WORK BSW/ MSW FIELD WORK APPLICATION pg3
All students are expected to follow the policies and procedures found in the BSW or MSW Field
Education Manual and the NASW Code of Ethics. Therefore prior to beginning a field practicum, all
students are required to read and agree to the following:
1. I understand I am responsible for reading and understanding field policies and procedures. Prior to
beginning my field placement, I will review the contents of the BSW or MSW Field Education Manual with
emphasis on:
 Attendance requirements at the agency and field seminar
 Evaluation and Grading
 Standards of Ethical Behavior
 Procedures for addressing placement concerns and termination from the field program
2. I will provide all documentation relevant to field education, completed accurately, to the agency and /or field
office on or before their required due dates, starting with this Field Work Application. I understand that I
jeopardize my placement opportunities if I fail to do so.
3. I am aware that my prompt response to emails and phone calls from the field office or any member of my Field
Education team demonstrates profession standards of regard and responsibility. Demonstration or lack thereof
of this standard will be reflected in my Field Evaluations.
4. I agree to accept supervision and instruction from the agency Field Instructor and (if needed) the Site –
Supervisor and the Field Seminar Liaison. I will participate in the development of my social work skills by
active involvement in field seminar, field supervision and the Student Evaluation process.
5. Furthermore, I understand that Social Work Field Education is a team effort and my Field Instructor and Liaison
will be in communication with each other and with the Field Education Coordinator as needed to discuss and
support my progress.
By signing, I agree the above conditions and expectations.
Student signature__________________________________________
Printed name_____________________________________________
Date__________________
NMSU SCHOOL OF SOCIAL WORK BSW/ MSW FIELD WORK APPLICATION pg 4
PLEASE SUBMIT A COPY OF YOUR RESUME ALONG WITH THIS APPLICATION.
DETERMINATIONS OF ELIGIBILITY TO NEW MEXICO SOCIAL WORK LICENSURE
Answering the following questions is required of all applicants for field placement and for determinations of eligibility to New
Mexico Social Work Licensure following graduation. Omission of any information may result in our inability to process your
application and provide a field placement for you. Provision of this information will not affect your standing in the social work
program but it may limit the type of placement setting you will be assigned to. This information will not be shared with a field
agency without your express permission. Many agencies have specific background and criminal record check procedures that
you must agree to for placement in that agency.
FALSE STATEMENTS ON THIS FORM WOULD BE EVIDENCE OF UNETHICAL BEHAVIOR AND CONSEQUENTLY GROUNDS FOR
TERMINATION FROM THE SCHOOL OF SOCIAL WORK.
1.
Have you ever used another name under which records may be filed concerning your application, or your education,
training, or experience leading to your application? Yes _____ No _____
2.
Criminal record
a. Have you ever been convicted of a felony, DUI/DWI or other criminal offense other than a minor traffic violation, or
are there such charges pending against you at this time? Yes: ______ No: ______
b. Have you ever had an allegation of either child abuse or adult abuse made against you that was substantiated or is
pending against you at this time? Yes _____ No _____
If you answer “Yes” to any of the questions above, you must provide documentation on the nature of the offense/allegation and
its disposition and a statement containing proof of rehabilitation if applicable. Please attach this information to your Field
Application even if you have submitted the information along with your application to the School of Social Work.
Convictions and pending convictions may limit opportunities for field education, professional licensing and future
employment.
3.
Have you ever been denied a license or permission to practice Social Work or permission to take an examination to
practice Social Work in any state, country, or territory? Yes __ No __ (If yes, please attach a complete and
comprehensive explanation)?
4.
Has any disciplinary action ever been taken regarding your practice or Social Work or any license you hold or have held to
practice Social Work? Disciplinary actions include, but are not limited to, suspension, probation, practice limitations,
reprimand, letter of admonition, censure and any allegations currently pending? Yes __ No __ (If yes, please attach a
complete and comprehensive explanation).
5.
Have you ever voluntarily surrendered a license to practice Social Work in any other state or territory? Yes __ No __ (If
yes, please attach a complete and comprehensive explanation).
__________________________________________________________
(Student’s Signature)
___________________
(Date)
STUDENT FIELD AGREEMENT WITH AGENCY
New Mexico State University School of Social Work
If student is seeking to complete the field practicum in his/her place of employment, please use separate form
entitled NMSU SCHOOL OF SOCIAL WORK FIELD WORK AGREEMENT IN STUDENT’S PLACE OF EMPLOYMENT.
Additional paperwork must be completed and approval granted before the first day of the practicum semester .
STUDENT INFORMATION (check one)
BSW
First year MSW
Second Year or Advanced Standing MSW
Student Name:
Interview with Agency Date:
Student Home Phone:
Cell Phone:
Other Phone:
Student Address:
City:
NMSU E-Mail:
State:
Zip Code:
FIELD INSTRUCTOR INFORMATION
BSW or MSW Licensed Agency Field Instructor should complete this portion
Agency Name:
Component(s) of Agency Student placed in (if relevant)
Agency Address:
City:
Field Instructor:
Position:
Phone Number:
Credentials/degrees:
Zip:
E-mail Address:
LBSW
LMSW
LISW License #
AGENCY BASED FIELD SUPERVISOR INFORMATION
(If daily supervision will be provided by someone other than Licensed Agency Field Instructor)
Agency Based Field Supervisor::
Phone Number:
Position:
E-mail Address:
Credentials/degrees:
NMSU Social Work Students are required to demonstrate competency in ten areas of knowledge necessary
to professional Social Work during the field placement. This is done through mastery of practice behaviors
related to each Competency below.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Practice professional behavior (Demonstrate professional demeanor in behavior, appearance, and communication.)
Learn and apply social work ethical principles to guide professional practice
Apply critical thinking to inform and communicate professional judgments.
Engage with diverse clients in the practice setting
Engage in practices that advance social and economic justice
Engage in research-informed practice and practice-informed research.
Knowledge of human behavior and the social environment
Identify relevant policy in practice to advance social and economic well-being and to deliver effective social work services.
Identify the process needed to respond to contexts that shape practice
Learn to engage, assess, intervene, and evaluate with individuals, families, groups, organizations, and communities.
Any special conditions for this internship:
Click here to enter text.
STUDENT’S WEEKLY SCHEDULE IN FIELD - PROPOSED
Day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Field Experience hours
(15 average 1st year
field and 17 average
2nd year field hours per
week - minimum)
including 1 hour of
weekly field seminar
Hours that you will
be in class or field
seminar
Work hours Only (Field
hours must be separate
from work hours)
to
to
to
to
to
to
to
to
to
to
to
to
to
to
_________________
SIGNATURES
After interviewing the above student our agency has agreed to accept the student for a social work field
experience placement and provide the students with an opportunity to develop and practice their
competencies.
BSW or MSW Licensed Agency Field Instructor Signature: _____________________________Date:______
(Attach copy of his/her resume and license)
Agency Based Field Supervisor: ____________________________________________
Student agrees to accept this placement:
Student’s Signature __________________________________________________ Date: _______
Student’s Phone Number at the Agency: ___________________________
Student’s Internship address if different than field instructor address (include component of agency’s name)
____________________________________________________________________________________
Placement must begin the first week of the semester
Placement approved by: _____________________________________ Date: _________________
Field Coordinator or Assistant Field Coordinator
Las Cruces: Please return to the front desk at the School of Social Work:
Attention: Field Team Staff
Albuquerque Students: Please return to Susan Burns, LISW, Field Coordinator
STUDENTS WILL NOT BE CONSIDERED OFFICIALLY IN THE FIELD UNTIL THIS FORM IS
RECEIVED
NMSU SCHOOL OF SOCIAL WORK
FIELD WORK AGREEMENT IN STUDENT’S PLACE OF EMPLOYMENT
3 pages
BSW
MSW First Year in Field
STUDENT NAME:
STUDENT HOME PHONE:
NMSU E-MAIL:
MSW Second year in field
CELL PHONE:
OTHER PHONE:
AGENCY NAME
AGENCY ADDRESS
CITY
ZIP
AGENCY PHONE
EXECUTIVE DIRECTOR OR ADMINISTRATOR NAME
CURRENT WORK SUPERVISORS NAME
PROPOSED FIELD PRACTICUM FIELD INSTRUCTOR
BSW
MSW
Student’s Employment In The Agency Length of employment at agency: yrs/months
Current Work Supervisor:
Field Instructor: Click here to enter text.
#_________
Click here to enter text.
If this is new employment to be used to fulfill a practicum experience, skip down to NEW
EMPLOYMENT Section
1. Student's current job title and job description:
2. What kind of work assignments does the student now have?
INFORMATION REGARDING PROPOSED PRACTICUM ASSIGNMENT:
Proposed Field Instructor (Attach copy of his/her resume and license)
1. Specify the new activities the student will do in the field placement.
2. How will the agency insure that the field experience will differ from the student’s job?
Student must complete in consultation with the Field Instructor, a Written Plan For Accomplishing SW
Field Education Goals And Practice Behaviors At Place Of Employment. Field Education Coordinator
has final approval of any practicum arrangement. See the last page for details.
NEW EMPLOYMENT STARTING ______
Current Work Supervisor:
Proposed Field Instructor (Attach copy of his/her resume and license)
OR
page 2
How will the agency insure that the field education requirements are met in addition to the work product
expectations?
Student must complete in consultation with the Field Instructor, a a Written Plan For Accomplishing SW
Field Education Goals And Practice Behaviors At Place Of Employment. Field Education Coordinator
has final approval of any practicum arrangement. See the last page for details.
STUDENT’S WEEKLY SCHEDULE IN FIELD - PROPOSED
Day
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Field Experience hours
(15 average 1st year field and
17 average 2nd year field
hours per week - minimum)
including 1 hour of weekly
field seminar
to
to
to
to
to
to
to
Hours that you will
be in class or field
seminar
Work hours Only (Field
hours must be separate
from work hours unless
employment is new and
will count towards
practicum.
to
to
to
to
to
to
to
If the agency plans to allow the student time off from their regular work schedule for field placement,
please indicate: Click here to enter text.
CONDITIONS FOR PRACTICUM IN PLACE OF EMPLOYMENT:
1. The student has completed the agency's probationary period or six months of employment unless the student is
a new employee (4 or less months) and will use the new employment itself in fulfillment of the practicum
experience.
2. The agency meets the standards for consideration as a field agency and is willing to sign or has signed an
affiliation agreement with New Mexico State University.
3. The agency has or has arranged to have a qualified MSW or BSW who can serve as field instructor.
4. The agency agrees that the student will have at least one hour of field instruction each week from the
designated MSW Field Instructor discussing the educational aspects of the practicum and will have adequate
time for record writing and other necessary preparation.
5. The agency agrees that the supervisor for the field is not the student’s supervisor for regular employment
6. The agency and the School of Social Work both agree that the assignments given to the student/employee are
consistent with the educational goals and objectives of the School and that the assignments show evidence of
sound educational design and progressive development of the student's abilities at the BSW or MSW level. This
will be documented in the student’s Field Work Learning Contract.
7. The agency agrees to this FIELD WORK AGREEMENT IN STUDENT’S PLACE OF EMPLOYMENT and
understands this may mean lighter caseloads, involvement in client and community based assignments not
typically assigned by the agency yet overseen by the Field Instructor, and agreed upon hours beyond the
normal work week. Hours in excess of the paid employment would not be paid by the agency, but considered
part of the Social Work practicum expectations.
AGENCY DIRECTOR Click here to enter text.
DATE______
Phone_________
CURRENT WORK SUPERVISOR Click here to enter text.
DATE______
Phone_________
FIELD INSTRUCTOR Click here to enter text.
DATE______
Phone_________
FIELD INSTRUCTOR Email Click here to enter text. (Attach copy of his/her resume and license)
STUDENT Click here to enter text.
DATE_____
Phone__________
REVIEWED BY FIELD COORDINATOR WITH THE FOLLOWING ADJUSTMENTS Click here to enter text.
FIELD COORDINATOR Click here to enter text.
DATE____________
Page 3
Written plan for accomplishing SW field education goals and practice behaviors at place of employment.



The School of Social Work recognizes that the activities of one's new or ongoing employment and
learning are not inconsistent, but there is an important difference in emphasis between the goals of
educational development and the delivery of service as a paid employee.
The agency and the School of Social Work must both agree that the assignments given to the
student/employee are consistent with the educational goals and objectives of the School and that
the assignments show evidence of sound educational design, progressive development of the
student's abilities at the MSW level, and autonomy in the attainment of these educational goals
and objectives. The agency and the School of Social Work agree that supervision and field
instruction will be provided by someone who is not the current or regular work supervisor.
If there are areas of focus required to fulfill the NMSU field education plan, but not available
through the student’s regular employment, the student may be required to take on assignments
not typically assigned by the agency. The student may be required to put in additional (unpaid)
practicum hours to accomplish these requirements, and the work will also be overseen by the Field
Instructor.
Please prepare a written plan that outlines how the competencies and practice behaviors necessary
to your specific year of practicum (1st or 2nd) will be addressed by your work duties. Make clear
reference to those areas that will require additional time and activities not associated with your work
duties and how they will be accomplished by you and your field instructor. You do not need to have a
specific action identified for each practice behavior specifically in this outline, but account for the general
areas that will be evaluated in your practicum and the specific time you’ll set aside to the attainment of
educational goals and development. Be sure to have your plan agreed to by your field instructor,
signed and dated by each of you. This proposal, while prepared with consultation with the field
instructor, should be written by the student, not the field instructor.
A Student will not be considered officially in the field until this plan and the
accompanying Field Work in Student’s Place of Employment form, are received and
approved by field coordinator .
PORTFOLIO OUTLINE
Get a three ring binder and use dividers to clearly separate each section of your portfolio
MUST BE REVIEWED AT MID-TERM & FINAL BY FIELD LIAISON
1. Section one
a. Table of contents for Portfolio
b. STUDENT DOCUMENT TRACKING FORM
c. Field Team Members
2. Section two – Choosing Social Work
a. Summarize your reasons for choosing social work as a profession; what you plan to do
with a social work degree and how this field placement experience will contribute to your
long term professional goals.
3. Section three – Syllabus and Field Policies
a. Field Course Syllabus (MSW 551& MSW 552 or MSW 554 & MSW 555)
b. Agency policies
 Related to client services
 Related to employment/practicum regulations
4. Section four – Contract and Evaluation
a. Field Learning Contract/Evaluation Document
b. Self evaluations (mid-term & final)
c. Mid-term and final evaluations signed by everyone in the field practicum team
5. Section five – Competency Based Assignments
a. Social Work Field Competency Assignments (each assignment will address a specific
competency)
6. Section six
a. Examples of client assessment including Genograms, eco-maps, culturegrams
b. PROCESS RECORDING: TWO PER SEMESTER
7. Section seven – Ongoing Documentation
a. WEEKLY SUPERVISORY MEETING AGENDA and TIME AND ACTIVITIES REPORT
(one per week)
8. Section eight - Research
a. Research articles related to your field placement
9. Section nine
a. Values and Ethics:
 One page summary of the values and ethics learned during field practicum
b. Summary of Field Experience
 What did you accomplish in this field placement this semester?
 What did you learned from supervision?
 Summary of leaning gains and your next steps for continuous professional growth.
STUDENT DOCUMENT TRACKING FORM – One per Semester
The student maintains this record until end of each semester. It is kept in the portfolio. It is the summary of
the time the students spent in the field, the weekly activities with their supervisor and the seminar
attendance and assignments.
Student Name______________________________________
BSW Semester Fall ______ Spring ______
MSW 1st Year Field Fall ______ Spring ______
MSW 2nd Year Field Fall ______ Spring ______
Filed Instructor Name: ______________________ Field Liaison Name: ____________________
Learning Contract submitted:
Mid Term Meeting
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Date: ____________
Date: ____________
Final Meeting Date: ____________
Weekly Supervisory Agenda/ Time
and Activities reports submitted
Seminar Attendance
Week of ________ time included__________
Week of ________ time included__________
Week of ________ time included__________
Week of ________ time included__________
Week of ________ time included__________
Week of ________ time included__________
Week of ________ time included__________
Week of ________ time included__________
Week of ________ time included__________
Week of ________ time included__________
Week of ________ time included__________
Week of ________ time included__________
Week of ________ time included__________
Week of ________ time included__________
Week of ________ time included__________
Week of ________ time included__________
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Week of _________
Week of _________
Week of _________
Week of _________
Week of _________
Week of _________
Week of _________
Week of _________
Week of _________
Week of _________
Week of _________
Week of _________
Week of _________
Week of _________
Week of _________
Week of _________
Total Time____________
Evidence of Learning
Competency Based
Assignments
1.
2.
3.
4.
5.
Date________
Date________
Date________
Date________
Date________
Competency Based
Assignments
Process recording
6.
7.
8.
9.
10.
1.
2.
Date_________
Date_________
Date_________
Date_________
Date_________
Date________
Date________
Agency or Case
or
Biopsychosocial
Presentation
Date________
Recommended Grade for Semester 1 or 2 is __________ (circle semester) ( U or S for MSW 551 only)
Liaison Signature ____________________
Date______________
A copy of this form should be in Portfolio. Give original to field office at end of semester.
SCHOOL OF SOCIAL WORK
WEEKLY INSTRUCTIONAL MEETING AGENDA and TIME AND ACTIVITIES REPORT
Week: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Student Name _________________________
Date of meeting: ______________________
DATE
ACTUAL
HOURS
Field Social Worker_______________________
Time of meeting: _____________________
DESCRIBE ACTIVITIES IN DETAIL Example: Conducted a client intake,
attended a staff meeting, completed an intake interview, called clients, call agency
X to make a client referral, etc.
Total Hours Accrued this week: ________ Remaining Hours to be completed: _______________
A minimum of 225 per term is needed for MSW 551 and 552 250 for MSW 554 and 555
Student’s Summary Report on the status of tasks assigned during last supervisory meeting:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________
Issue or issues student wants to discuss during this instructional meeting and their relationship to Social
Work Competencies>_____________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________
Learning tasks and assignments from this instructional meeting to be completed by next week:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________
Student’s Signature: _________________________________________ Date: ______________
Field Instructor Signature: ___________________________________ Date: _____________
If student is struggling to meet field requirements and/or has been advised to work on any social work
competency and there is concern that the student is not working towards meeting course requirements, the
Field Instructor must include a recommendation for improvement and explicitly inform the student of any
danger of failing the course. The Field Instructor must also notify the Liaison as soon as these issues occur.
(Use back of form if necessary)
This form should be completed weekly and included on the portfolio for liaison review
AGENCY PRESENTATION OUTLINE – FOR SEMINAR DISCUSSION MSW 551 and 554
This is intended as a brief simulation of a community presentation a social worker in your agency might
do to recruit clients or get other professionals to refer clients to your agency. This is a required seminar
presentation.
1. MSW Student Information.
 Student’s name: ______________________________________
 Date of seminar presentation: _____________________
1. Agency structure:
a. Description of the agency; historical background – date started and reason started and current
main activities.
b. Mission statement of this agency.
c. If the agency has several units, give an overview of the agency as a whole and explain how your
unit fits with the agency’s mission.
d. Sources of agency financial support.
e. Executive Director or CEO and names of Board members (if a non-profit).
f. Provide an organizational chart for your Portfolio.
2. Clients:
a. Describe client demographics: ages, ethnicity, income, etc.
b. Describe the issues that are most salient in this client population.
c. Agency's relationships to clients and community:
 Do they do field visits or is work mainly in the office?
 What community is served by agency, what neighborhood or region?
 What other networking agencies work with the agency?
3. Agency policies:
a. Describe agency policies regarding clients
b. Describe agency policies related to employees, volunteers and social work practicum students.
4. Type of Practice:
a. What forms of Micro Practice (direct service – individual, family and/or group methods) does the
agency use?
b. Is the agency involved in Macro practice? If yes, describe.
c. What social work theories are used in this agency?
d. What kind interventions does this agency apply? If not explicit evaluate what the agency does
and describe the interventions in terms of social work practice.
5. Provide a brief summary of your learning experience at this point.
MSW 552 FIELD SEMINAR
SOCIAL WORK BIOPSYCHOSOCIAL ASSESSMENT and INITIAL GOAL
PLANNING
One of the most important skills of a Social Worker is the ability to conduct a meaningful
assessment of their client. No matter what area of SW, we must be able to gather information
about our client’s concern, life experience, strength and limitations to be effective in our work.
We must be able to collect this information through direct questions and indirectly through good
attending and listening skills.
Information related to the Biological, Psychological, Social, Cultural and Spiritual makeup of our
client is essential to deliver service that is appropriate, culturally sound and involves the SW tenet
of the importance of looking at the Person- in –Environment for solutions.
To conduct an effective assessment the social worker needs the skill and ability to:
 Create an environment in which the client feels safe to discuss sensitive and personal issues.
 Establish rapport with the client.
 Apply active listening skills.
 Identify the client's interests, skills, abilities, obstacles, strengths, limitations, needs for
services, and personal resources.
 Help the client develop and set realistic goals to put into action plans and interventions.
 Use attending skills to observe and note the client’s physical appearance, body language, eye
contact, affect, dress, personal hygiene, speech patterns and cognitive abilities.
 Gather and incorporate relevant collateral information as needed to complete the assessment.
Guidelines for Goal planning:
 Goals need to relate to the results sought by clients or as agreed on to meet requirements for
clients referred involuntarily.
 Goals need to be feasible/practical, explicit and measurable
 Goals need to be consistent with the mission of the agency.
 It is best that goals be stated as positive changes/additions, not the reduction of something
unwanted. ( not to stop eating cake, but to add vegetables)
 Goals are to be broken into smaller objectives and even smaller interventions:
1. Goal: Increase my sense of contentment
2. Objective: Feel stronger physically
3. Intervention: walk 3 times a week for 20 minutes
A Biopsychosocial Assessment is a compilation of client information including at minimum, the
following information. Depending on the focus of the SW agency, there may be additional or
more specific questioning in each area.
A. Presenting Concerns and Identifying Information
 What is the client’s concern?
 What is the concern of the referral source or significant other/family members?
 How long has the problem existed?
 Why did the client seek help now?
B. Mental status: Cognitive functioning




Does the client seem to be of normal intelligence?
Is there evidence of logical problem-solving thinking or capacities?
Is the client’s thinking coherent and goal directed?
Does the client exhibit good judgment?
Physical/Medical





Does the client report any medical conditions or problems?
Does the client present with any disabilities?
Does the client use alcohol?
Does the client use any other substances?
Has the client experienced any social, occupational, or legal problems associated with his or
her use of alcohol and/ or other drugs?
Emotional
 What emotions does the client describe in relation to the presenting problem?
 Do the client’s emotions appear to be congruent with the client’s thoughts?
 How does the client’s dress, appearance and personal hygiene compare to current social
norms in regard to age and culture?
C. Relational and Social support systems
 Does the client have family, significant others, close friends and/or acquaintances that the
client feel are supportive relationships?
 Does the client’s presenting problem involve other family members or significant others?
 Can the family members or significant others be part of the solution?
D. Employment support network
 Is the client employed? Underemployed? Unemployed?
 What is the client’s occupation?
 Is work somehow related to the presenting concern?
School
 How does the child do in school?
 Does the client presenting problem affect his or her studies?
E. Diversity issues




What is the client’s ethnicity or nationality?
How acculturated does the client appear to be?
Is English the client’s first language? Second?
Does the client utilize any cultural resources?
Summarize what your professional opinion is regarding the impact of issues of diversity on
the clients presenting problem.
F. Barriers and Risk factors
 Does the client perceive barriers to accessing resources?
 Does the client appear to be a member of a vulnerable or special needs population?
 Does the client appear to have no resources of their own to help resolve the problem?
Summarize what your professional opinion is as regards the presence of barriers to service
or the use of resources. Are there larger issues of Social Justice and Equality at play here?
G. Goals of Client
 What does the client wish to change or accomplish by enlisting your help?
 What attempts has the client made to resolve the problem? If it is a recurrent
problem, what seemed to help resolve it in the past?
H. Strengths and resources




What do you perceive to be the client’s strengths?
How can these strengths be utilized to assist the client in resolving the current issues?
What client resources could be utilized to enhance coping?
What agency resources could be utilized to intervene with the client?
I. Other significant information as presented by the client referral source or significant or
observed by the social worker.
J. Mutually agreed-on definition of problem and goals.
 Summarize the clients concerns and presenting problem taking into account the
discussion of issues of diversity and potential social barriers
 After presenting your summary to the client, you and the client will need to arrive at a mutual
understanding of the problem to be addressed and what goals can be accomplished together.
K. Preliminary Treatment Plan
 Now that you and client have agreed on one or more workable goals that will address the
mutually agreed –on definition of the problem, you will need to clarify step by step Objectives
and then behavioral Interventions to accomplish the larger Goal.
 Goal:
 Objective:
o Intervention
Case Presentation Outline – for MSW 555
I. MSW Student Information.
Student’s name: _________________________ Date of seminar presentation: ______
II. Agency Information.
 How does your case reflect the mission and target population of your agency?
The Case (Individual, family, group, or community organization)
III. Assessment
A. Data gathering
 Description and identifying information, include referral source
 Presenting concerns
 Demographics and Cultural considerations
 Community – description of the community or social context of your client
B. Use of tools
(as appropriate)
 Genogram
 Eco Map
 Culturegram
 Multi-Axial ( DSM) assessment
 Forms /tools from your agency
 Group tool: mutual goal clarification
 Community and Organizational tools : needs assessment and community survey,
feasibility study, asset mapping
 Logic model worksheet for program development-start with desired outcome and build what
needs to happen to arrive there.
C. Theoretical Frameworks
Micro client levels: Explain the applicability of two behavioral and developmental theories
and Family Life Cycle factors used in the assessment of your case such as:
 Developmental stage and mastery of what psychosocial skills?
 Issues concerning separation, loss and relationship attachment?
 Developmental stage of the Family
 Stage of Moral Development










Mezzo client levels: Group Development -Stages of Group Development:
Preaffiliation, Power and Control, Intimacy, Differentiation, and Separation.
Examine members roles
Patterned behavior
Group alliances
Power and Decision-making styles
Group norms, values and cohesion
Macro client levels: Community and Organizational development- addresses the outer
layers of an eco-map. This is where the problem, population and
community/organization overlap with Formalized policy and Political Environment, and
change is at the system level, not individual.
Empowerment Model-promote social and economic justice when communities are able to
secure the resources they need to change their situations.
Advocacy and Social Action model- the community itself takes action to address concerns.
Social Planning model–expert driven and consultant problem solving.
Capacity Building model- increase ability of community to act on own behalf.
D. Risk and Protective Factors
IV. Intervention
 What are the goals, objectives and interventions you are working on and discuss how they
relate to a practice theory you are using as your model
V. Termination of case
 How are you discussing termination with your client?
 How are you managing your own sense of loss and change?
VI. Ethical Issues
 Describe one ethical issue or dilemma in your case.
VII. Policy Implications
 Explain the agency, local, state and federal policies relevant to your case.
VIII. Social Justice Concerns
 Comment on social justice issues in your case
IX. Literature Review
 In order to demonstrate knowledge of and the ability to apply evidence based practice,
students should prepare a brief literature review. This literature review should:
 Be directly relevant to the main intervention used in your case presentation.
 Describe what the scientific literature reveals about the effectiveness of the intervention
used.
 Be directly relevant to the client system used in your case presentation.
 Please refer to previous course work to present your findings in format appropriate
to empirical based literature reviews. Present two articles or books/chapters.
X. Evaluation:
 Critique how effective your work has been in helping your client gain clarity, develop a
commitment to change, gain new perspectives, or accomplish the purposes of your contact
with the client.
 What did you use to evaluate this?
.
PROCESS RECORDING: DEMOGRAPHICS
Students will conduct two process recordings each semester.
The process recording is a learning tool that is meant to allow students to record an interaction with a client and evaluate their actions, the social
work skills used in the interaction, and their feelings related to the situation or client and thinking process. The Field Instructor reads the process
recording and provides the student with feedback, questions or makes observations to help the student further develop their social work skills.
1. Identifying Information.
 Student's name: _____________________________
 Field Instructor’s Name ____________________________
 Date of session: _____________________
2. Background Information.
Include any information necessary to understand the interaction described in the recording. This includes any information you know about the
client including:
 Client's initials or fictitious name ________ Sex _______ age ________ race/ethnicity __________
 Referral source ___________________________________________________________________________
 Why referred __________________________________________________________________________________________________
 Family background: Any significant intergenerational connections from genogram ______________________________________
____________________________________________________________________________________________________
 Number and types of other contacts you have had with the client(s) ______________________________________________________
 Describe setting - who is present: _______________________________________________________________________________
A brief summary of work to this point with this client: __________________________________________________________________
________________________________________________________________________________________________________________

In the case of a Group, describe how the group was formed, how recent is its formation, and what are the characteristics of those who make
up the group
 In the case of Macro Practice, identify your client system(s), provide background information about the agency and/or community and about
the project itself including any needs assessments that have been done, committee work done or ongoing, etc. Additionally, review your
involvement in the project and specify your roles as the social worker involved in the project.
Relevant Practice Behaviors That Should be reflected in the PROCESS RECORDING
1. How do you demonstrate empathy and other interpersonal skills
2. How do you collect, organize, and interpret client data
3. How did you practice personal reflection and self-correction with this client
4. Were you aware of professional roles and boundaries?
5. How did you demonstrate professional demeanor in behavior, appearance, and communication
6. Did you use supervision and consultation as needed?
7. Did you recognize and manage personal values in a way that allows professional values to guide practice.
8. Did you demonstrate effective oral and written communication in working with individuals, families, groups, communities, organizations, and
colleagues?
9. Did you gain sufficient self-awareness to eliminate the influence of personal biases and values in working with diverse groups?
10. Did you view yourself as a learner and engage those with whom they work as informants.
.
PROCESS RECORDING FORMAT FOR 15 MINUTE INTERACTIONS WITH CLIENT/CLIENTS:
Erase all of the instructions when doing your own process recording
ELIMINATE THESE INSTRUCTIONS WHEN YOU HAND IN YOUR PROCESS RECORDING. YOU ONLY NEED THE HEADINGS
Interview
Social work skills
used
Feelings (your emotional
reaction)
Thoughts (your
Assessment
Field Supervisor’s
comments
Replace the word student with your name
and & client with initials and record exact
words spoken by both you and the client
during the 15 minute interaction
Here, discuss the social work
skills you used at each step in
the process.
Here, opposite the dialog, record
how you were feeling as the activity
or communication was taking place.
Do not use this column to analyze
the client's reactions - use it to
identify and look at your gut level
feelings. Be as open and honest as
you can - tell it as you feel it
Here, opposite the dialog, record
what you were thinking regarding
assessment of the client situation.
In this column, your Field Instructor
will make remarks opposite the
interaction or gut-level feelings that
have been recorded, as well as
opposite the thoughts regarding
assessment.
Example:
Example:
Example:
I used engaging skills by
introducing myself in a ….
manner.
I was nervous because it was my
first interview without my supervisor.
Be certain to include third-person
participants, interruptions, and other
occurrences that were not part of the
planned Interview
Example:
Marsha: Hi, I’m Marsha from …….
Mr. Jones: We weren’t expecting you.
Competency demonstrated
I felt uncomfortable because of my
appearance and felt I may have
come across as being intimidating
You Field Instructor must make
comments on this document
before you hand it in.
Observed outside area of the home
once I arrived and noticed that it
was much cluttered with broken
windows. Once I was inside Mr.
Jones was surprised by my visit and
was a little hostile at the beginning
until I clarified the purpose of my
visit.
.
NMSU SCHOOL OF SOCIAL WORK
CHANGE OF FIELD PLACEMENT REQUEST
The School of Social Work has a process for Resolving Problems in Field Placements.
Please follow the process and document it in this request form. Social Work Field
Placements should be for one academic year. If there is a need to move a student from an
agency midyear, this form must be completed to start the change process.
Student Name: ___________________________________
email: ________________
Liaison Name: ________________________________________ email: _________________
Field Instructor: _______________________________________ email: ________________
Agency Name: ____________________________________
Name of Person Initiating this Request _____________________Telephone # (___________)
A field placement change is generally needed when the agency or field instructor is no longer
able to provide the student with instruction or a learning environment. Poor student performance
does not lead to a change of placement but may result in a failing grade in the field.
REQUIRED MEETINGS:
1. The Field Instructor And Student Must Meet To Discuss The Problem.
2. If The Problem Isn’t Resolved, They Must Meet With The Field Liaison.
These Meetings Must Be Held To Address Problematic Issues Before A Request For
Change Of Field Placement Can Be Made.
CHECK ALL THAT APPLY
STUDENT CONCERNS
Qualifies for a change of placement:
o Agency unsafe and/or ethical
problems
o Insufficient instruction regarding
field assignments.
o A need for greater responsibility or
client contact.
o Lack of opportunities to learn and
practice the 10 competencies
o Lack of Field Instruction - Field
Instructor doesn’t meet with
student once/week
o Incomplete orientation.
o Loss of Field Instructor due to
person leaving the agency or
taking another assignment.
o Field Instructor unable to explain
how to improve.
o Paperwork not read by Field
Instructor – student unable to
complete coursework due to lack
of feedback from instructor
The following do not qualify for
an agency change but are issues
that need to be addressed.
o Field liaison not available
o Field seminar is not meeting once
per week
o Field instructor & liaison did not
provide a reason for assigning the
student a poor grade.
FIELD INSTRUCTOR CONCERNS
Qualifies for a change of placement:
o Instructor will no longer be able to provide instruction and
supervision for the student.
The following are examples of behavior that do not qualify
for an agency change. A FAILING GRADE IS MORE
APPROPRIATE.
o Student's poor performance in basic work place
responsibilities (e.g. poor attendance, misuse of time).
o Inappropriate attire or demeanor
o Unwillingness or inability to be proactive in own learning.
Work completed minimally.
o Negative attitudes toward clients, colleagues, or the agency
o Problems in personal functioning (health, mental health,
substance abuse at agency) sufficiently serious to interfere
with student learning or endanger client welfare.
o Lack of boundaries towards clients and towards other
workers in agency. Clients' rights violated
o Inability to engage clients despite repeated supervision and
training
o Inability to apply theory to practice despite discussion in
supervision, demonstration and training
o Continual inaccurate, late or poorly written paperwork after
training
o Inability to follow directions
o Continued and persistent need of close supervision after
three months in practicum.
o Inability to seek and use supervision without defensiveness
o Agency programming has been disrupted by student
behavior.
o Questionable ethical behavior
o Arriving at placement under the influence of alcohol or
another substance.
o Inability or unwillingness to follow chain of command:
FIELD LIAISON CONCERNS
o Inflated field grades – instructor
assign the highest marks but
does not provide documentation
to support the grade.
o Lack of weekly supervision –
weekly meeting agendas are
incomplete or missing.
o Lack of documentation – no
comments on student’s
paperwork
o Instructor did not inform the
student about poor performance
concerns until the mid-term or
final meeting.
o Instructor waited until a crisis to
contact the Field Liaison
o Lack of progressive evaluation
leading to student’s failure in field
without documentation. Poor
performance was not
documented on the weekly
meeting agendas.
The following are examples of
behavior that do not qualify for
an agency change. A FAILING
GRADE IS MORE
APPROPRIATE.
o Student’s poor performance or
lack of attendance in seminar
o Student’s poorly written
paperwork
o Student unable to accept and use
redirection without defensiveness
o Student leaves placement.
.
CHANGE OF FIELD PLACEMENT REQUEST page two
Field Team Meetings
1. Student’s input concerning the issue or issues:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________________________________________________
2. Liaison’s input concerning the issue or issues:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________________________________________________
3.Field Instructor’s input concerning the issue or issues:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________________________________________________
4.Summary of the meetings: Please document the times, dates, people attending and content
of discussion and other documentation of each meeting. There must be a specific action plan
developed.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________________________________________________
5.Recommendation from Liaison and Instructor concerning change of placement:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
______________________________________________________________________
SIGNATURES: This request will not be considered by the Field Program unless signed
by student, field instructor, and faculty field liaison.
Name
Signature
Date
Student
Field Liaison
Field Instructor
Field Coordinator
Field Coordinator’s Determination:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Form adapted from: University of Houston, Graduate College of Social Work, and Office of Field Practicum
.
STUDENT EVALUATION OF FIELD AGENCY
Date: __________________
Check one: BSW 402 □ MSW 552 □ MSW 555 □
Agency Name:
Please circle the number that represents your rating
(1) Not at all or most negative
(4) Most of the time or better than
average
(2) Rarely or negative
(5) Always or most positive
(3) Sometimes or average
1 2 3 4
The agency has clear policies and procedures for student interns.
1 2 3 4
The agency has accessible safety plans, sexual harassment, and grievance procedures.
This agency provides opportunities to develop and practice Social Work competencies and 1 2 3 4
practice behaviors.
1 2 3 4
The agency provides student interns the opportunity to participate in staff meetings and
training events
1 2 3 4
OVERALL, I WOULD RATE THIS AGENCY:
I would recommend this placement to other students because…. (please give written comments – use back
of page if needed)
5
5
5
5
5
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
I would not recommend this placement to other students because…. (please give written comments – use
back of page if needed)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
.
STUDENT EVALUATION OF FIELD INSTRUCTOR
Date: __________________
Check one: BSW 402 □ MSW 552 □ MSW 555 □
Please circle the number that represents your rating
(1) Not at all or most negative
(4) most of the time or better than
average
(2) Rarely or negative
(5) Always or most positive
(3) Sometimes or average
Field Instructor’s Name:
___________________________________________
THE SOCIAL WORK FIELD INSTRUCTOR
1 2 3
Provided an orientation to the agency, and made the expectations for student
performance clear.
1 2 3
Helped me understand the agency’s purpose, policies, and procedures including safety
plans, sexual harassment, and grievance procedures.
1 2 3
Assigned projects, cases and reading materials to assist me with the understanding,
development and practice of field competencies.
1 2 3
Reviewed and commented on two process recordings each semester.
1 2 3
Reviewed and commented on my mid-term and final evaluations.
1 2 3
Assisted with the Field Learning Contract and Evaluation document
1 2 3
Provided individual educational instruction to each student at least once a week and
provided on-going performance feedback utilizing the INSTRUCTIONAL MEETING
AGENDA and the TIME AND ACTIVITIES REPORT.
1 2 3
Provided assistance/support when needed and gave me the opportunity to make
mistakes, recover and learn from them.
1 2 3
Participated in meetings with the field liaison to review my progress, as well as review my
performance during mid-term and final evaluations.
1 2 3
Overall, I would rate this social work FIELD INSTRUCTOR
I would recommend this social work field instructor to other students because…. (please give written
comments – use back of page if needed)
4 5
4 5
4 5
4
4
4
4
5
5
5
5
4 5
4 5
4 5
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
I would not recommend this social work field instructor to other students because…. (please give written
comments – use back of page if needed)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
.
STUDENT EVALUATION OF FIELD LIAISON
Date: __________________
Check one: BSW 402 □ MSW 552 □ MSW 555 □
Please circle the number that represents your rating
(1) Not at all or most negative
(4) most of the time or better than
average
(2) Rarely or negative
(5) Always or most positive
(3) Sometimes or average
Field Liaison’s Name:
1 2
Met with us once per week for group seminar and provide instruction and feedback
regarding field expectations regarding the Learning Contract and Evaluation,
assignments, process recordings and portfolio.
1 2
Assisted us in integrating classroom and field experience learning.
Provided instruction and guidance regarding cases, agency activities, and field concerns. 1 2
Helped us understand the chain of command to resolve any field problems STUDENT ► 1 2
FIELD INSTRUCTOR ► FIELD LIAISON ► FIELD COORDINATOR
1 2
Advised me regarding field performance, evaluation, and assigned the final grade
1 2
Visited the agency and maintained an ongoing relationship with me and the agency field
instructor
1 2
Met with me and my field instructor to discuss my progress and answer educational
questions related to my professional development during mid-term and final.
1 2
Evaluated evidence of my performance in the field agency, seminar and all course
assignments to calculate my final grade at end of the semester.
1 2
Was available to mediate any issues between, the student, the agency field Instructor,
site supervisor and the school to develop a course of action to resolve the Field Situation.
1 2
Overall, I would rate this FIELD LIAISON
I would recommend this social work field liaison to other students because…. (please give written
comments – use back of page if needed)
3
4 5
3
3
3
4 5
4 5
4 5
3
3
4 5
4 5
3
4 5
3
4 5
3
4 5
3
4 5
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
____________________________________________________________________________________________
I would not recommend this social work field liaison to other students because…. (please give
written comments – use back of page if needed)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________________________________