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Boston University School of Social Work

264 Bay State Road, Boston, MA 02215

CHARLES RIVER CAMPUS – Foundation (First) Placement Form – Continuing PT Students

This form will be used to plan your field experience. Please complete and email this form along with a current resume to .

Summer Block September to May

Name:

E-mail: Student Terrier Card #: U

Present address:

Phone #s: home: work: cell:

Summer address and phone #:

Anticipated address for the coming year:

Education - School Degree Date Major

Relevant work experience –

Agency Position Date Paid or Volunteer

Will you have access to a car for your placement? Yes No

If you can practice professionally in any language(s) other than English, please specify language(s)

Please specify the METHOD CONCENTRATION which you are currently considering (check all that apply):

CLINICAL: Individuals Families Groups

MACRO: Community Organizing Management Planning

Please specify MACRO Minor (if applicable): Yes No

Have you already been accepted to or enrolled in a dual-degree program:

Public Health Education Theology

When do you plan to do your advanced (second) placement?

1/09

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BOSTON UNIVERSITY SCHOOL OF SOCIAL WORK

FIELD EDUCATION DEPARTMENT

EDUCATIONAL ASSESSMENT

Student's Name: Advisor:

Please complete the following assessment

1. Educational and Professional Background (include discussion of work and volunteer

experience and previous area of study). What relevant knowledge and skills do you bring

from these experiences?

2. Learning Style:

a) Describe your characteristic learning style

b) Comment on your level of independence in learning situations

c) What type of setting would be best for you (e.g. large or small, multi-disciplinary or all social

work, primary or host)?

d) What information would be helpful to a potential field instructor to support your learning?


3. Learning Needs and Goals

a) Have you defined a career path or goal? Yes No

Please describe briefly:

b) What knowledge and skills do you want/need to acquire in your foundation placement?

c) Are there particular populations, modalities or social problem areas on which you want to

focus in your foundation placement?

d)  Are there particular populations or modalities on which you should not focus in your

foundation placement? If yes, please explain:

4. Learning Issues

a) Describe any learning problems you had in the academic program.

b) How were these problems resolved and how might they impact the field placement?

5. Other

Please describe other factors which might play a role in your placement (include day and

time constraints, physical or geographic considerations).

*If you have a disability which may require specific accommodation in your field placement,

we encourage you to talk to a member of the Field Education staff. Please note that such

disclosure is optional.

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Student Signature Date


Please answer the following questions:

(Optional)

1. Birthdate

2. Gender Identity

3. Ethnic/Racial/Cultural Identity

The next few questions address your educational interests and career goals. Your answers will help us identify a foundation field placement that will build on our previous experience, introduce you to new populations and fields of practice, and support your professional goals. Please keep in mind that the foundation placement is designed to expose you to both clinical and macro practice. In order for us to make thoughtful assignments, it is essential that we have an electronic copy of your resume along with this form.

4.  It is recommended that you save your area of specialization for your advanced (2nd) placement. Please describe the type of setting you believe will best support your learning style in your

foundation (1st) placement:

5. If there is any additional information about you or your background that would be helpful for us to

have in making your assignment, please comment: