St. Catherine University and University of St. Thomas

ST. CATHERINE UNIVERSITY AND UNIVERSITY OF ST. THOMAS

SCHOOL OF SOCIAL WORK

FIELD INSTRUCTOR AGREEMENT FORM

Cover Sheet

Field Instructor Name: ______

Student name (if known): ______

I intend to supervise (check all that apply): BSW student(s) ______MSW student(s) ______
Please complete and sign the form, and return the form and this cover sheet by mail or fax to:

School of Social Work
St. Catherine University and the University of St. Thomas
2004 Randolph Ave., Mail: F-15
Saint Paul, MN 55105
Office Fax: 651-690-8821

(You may also email a scanned version, with your signature, to Christa Bobick: )

For Office Use Only:

Reviewed by Field Director/Coordinator (initials): ______

Eligible as Field Instructor for: BSW ______MSW Foundation ______MSW Clinical ______

Comments:

Entered in IPT: ______(entry date)

ST. CATHERINE UNIVERSITY AND UNIVERSITY OF ST. THOMAS

SCHOOL OF SOCIAL WORK

FIELD INSTRUCTOR AGREEMENT FORM

NAME: DATE:

AGENCY NAME:

AGENCY ADDRESS:

(Street) (City/State) (Zip)

OFFICE PHONE: ______CELL PHONE:

JOB TITLE: ______E-MAIL ADDRESS:

LICENSED SOCIAL WORKER? / Level of Licensure in MN: / Level of Licensure in other state:
_____Yes / _____LSW / ______State
_____License # / _____LGSW / ______Level
_____Pending / _____LISW
_____No / _____LICSW

Your signature affirms your agreement to provide direct supervision for the social work students placed in your agency and to fulfill the following responsibilities:

Participate in the Field Instructor Orientation

BSW: held in August for seniors and October for juniors
MSW: held in August for academic year placements, and May for summer block placements

Participate in seminars, workshops, and other special activities arranged by the Directors of BSW/MSW Field Education
Select appropriate assignments and with the student create a field agreement (BSW) or field education contract (MSW) which reflects pathways to acquire the core competencies.
Provide for the student an orientation to agency and job/task.
Provide regularly scheduled formal supervision per the requirements of the program (BSW or MSW).
Provide on-going supervision and evaluation of your student throughout the placement.
Participate in meetings with the student and faculty liaison throughout the field placement, usually two per school year.
Complete and submit requested materials to the field education program (e.g., field instructor agreement form, student evaluations, etc.), in electronic or hard copy formats, as required.
Work collaboratively with the field faculty liaison and student to identify both strengths and areas for professional growth and maximize the student’s potential for success.
Notify the field faculty liaison of any problems or questions as soon as they become evident.

______

(Signature) (Date)

(over)

UNDERGRADUATE COLLEGE EXPERIENCE

NAME OF COLLEGE

LOCATION: (City, State)

MAJOR: MINOR AREA OF EMPHASIS:

YEAR OF GRADUATION: DEGREE:

GRADUATE EXPERIENCE

NAME OF COLLEGE:

LOCATION: (City, State)

AREA OF CONCENTRATION:

YEAR OF GRADUATION: DEGREE:

PROFESSIONAL WORK EXPERIENCE (LIST CURRENT POSITION FIRST)

AGENCY NAME: AGENCY SUPERVISOR:

AGENCY LOCATION:

(Street) (City/State)(Zip)

JOB TITLE: Circle one: FULL-TIMEPART-TIME

DATES WORKED AT THE AGENCY: FROM: TO:

Month and Year Month and Year

JOB DESCRIPTION: