Field Practice Learning Agreement and Evaluation Form

SOCIAL WORK PROGRAM

Field Practice Learning Agreement and Evaluation Form

Brief Instructions: Please see field manual, available at www.sjc.edu/social-work-forms

for complete instructions and for additional downloadable copies of this form.

Learning Agreement (September & January)

The Learning Agreement (planned activities) portion of this form is to be completed by the student with guidance and approval from the field instructor within the first four weeks of the field placement. The Field instructor will retain the original and submit a copy to the faculty liaison.

A new Learning Agreement will be completed for the spring semester carrying forward relevant objectives. We recommend completing and maintaining electronic versions of this document.

Evaluation (December & May)

At the end of the semester, the field instructor will complete and submit the evaluation to the social work office after reviewing the evaluation with the student and obtaining the student’s signature.

Student Name:
Semester: / Fall / Spring / Year: / Junior / Senior
Agency:
Field Instructor:
Address:
Telephone: / Cell Phone:
Email:
Additional Agency Supervisor:
Internship Schedule: days/hours:
Supervision Schedule: / Day: / Time:
SJC Faculty Liaison:
SUMMARY PAGE

Description of generalist social work assignments:

Individuals, Groups & Families assignments: (For example, list specific number and type of individual, group, family cases and whether the student is assigned to be primary worker,

co-facilitator, observer etc.)

Community/Policy Practice assignments: (For example, students might be assigned to research a policy and its impact on clients; track a legislative initiative; interview clients to learn their perspective as service recipients; participate in a committee writing new policies for the agency; or participate in a coalition)

Participation at regular staff meetings, agency trainings, and other general agency activity:

Planned attendance at professional conferences, workshops (minimum of one professional development activity required each semester)

______

Field Instructor Date

______

Student Date

______

Faculty Liaison Date

STUDENT ORIENTATION:

Checklist of orientation activities designed to build student knowledge:

Field Instructor/Supervisor orientation activities:

Schedule supervision sessions to orient the student to agency,

Review practice standards, policies, and customs such as dress code, lunch patterns, etc.

Send out memo/email to staff introducing the student;

Provide tour of agency;

Introduce student to clerical staff and provide orientation to making copies, printing, telephone, email/internet systems.

Student orientation activities:

Student review of agency policy manuals; brochures, program materials

Student meeting(s) with administrative and program staff; Please specify:

Student visit(s) to community programs and resources, tour of neighborhood, specify:

Field instructor/supervisor review of agency protocols; instructions for how students should respond to:

transportation of clients;

mandatory reporting, child abuse, elder abuse

suicide/homicide threats

drugs/alcohol,

weapons,

safety issues

Other:

In September: At the beginning of the semester use the space below to identify student learning activities that will facilitate the assessment of the competencies listed. See suggested assignments for each competency in the Learning Contract Tool Kit document attached

In December: At the conclusion of the semester use the scale below each competency to assess the student's achievement of each of the competencies and practice behaviors identified in this Learning Agreement and Evaluation Form.

Competence #1: Intern identifies as a professional social worker and conducts
himself/herself accordingly. Assignments should involve: client advocacy, understanding of professional development and deportment, professional roles and boundaries, and the use of supervision.
LEARNING OPPORTUNITIES AND STUDENT ACTIVITIES TO ACHIEVE COMPETENCY One
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