Employee-Based Placement Proposal

Employee-Based Placement Proposal

Please consult with agency staff when drafting this proposal and type your responses below.

Today’s Date______

Student Information

Name of Student: ______

Junior or Senior Field: ______

Proposed Semester of Internship: ______

Current Job Title at Agency:

______

Current Role and Responsibilities at Agency: ______

Agency Information

Agency Name: ______

Agency Address: ______

Agency Website ______

Agency Phone Number ______

Unit/Department where student works: ______

Student’s Current Agency Supervisor

Name: ______

Email: ______

Phone Number: ______

Current Job Title at Agency:

______

Current Role and Responsibilities at Agency: ______

Proposed Field Instructor Information

The proposed Field Instructor should be someone other than the student’s current employment supervisor. Students can propose an External Field Instructor, if necessary.The student must have the proposed Field Instructor complete a Field Instructor Information Form and include this form when submitting this proposal.

Name: ______

Email: ______

Phone Number: ______

Current Job Title:

______

Current Role and Responsibilities: ______

Is the proposed Field Instructor employed by your agency? Yes ____ No ____

Are you proposing to use an external Field Instructor who has not yet been identified?

Yes ____ No ____

Proposed Agency Field Coordinator Information

If the Field Instructor is not an agency staff member or is not on-site at the location where the students will complete their internship hours, the agency must be willing to assign a staff member to serve as an Agency Field Coordinator(site supervisor). The proposed Agency Field Coordinatorshould be someone other than the student’s current employment supervisor.

Name: ______

Email: ______

Phone Number: ______

Current Job Title at Agency:

______

Current Role and Responsibilities at Agency: ______

Social Work Internship Information

Students’ duties should be different from that of their current position. Since students will be in the role of social work intern, their duties should be specific to the role of a social worker in that setting.

Unit/Department where student will work: ______

Proposed Job Tasks as a Social Work Intern:

______