Student Field Placement Form

Student Internship Information Form

This form gathers information about a student's internship to ensure timely communication between the University of Maine School of Social Work and Internship Agency. It is important to complete this form as accurately as possible. Please note: If any of information about the student, agency, or staff changes during the internship students must complete another field placement information form.

Today's Date(Required)

Student Information

Student's Name(Required)

First Last

Student's Preferred Phone Number(Required)

Student's University of Maine Email Address(Required)

Please enter your University of Maine email only.

Student Emergency Contact

Please list the name and phone number of an emergency contact you give the University & Agency permission to contact in case of an emergency while you are in your internship

Which is Your Program? Your Course? The Semesters of Your Internship?(Required)

Minimum Number of Internship Hours(Required)

Student's Beginning Semester in Internship(Required)

Please enter the semester you will begin placement. IMPORTANT: If you are updating this form choose the semester you began field.

What is the Structure of this Internship?(Required)

Is this a New Internship or Are You Updating Information About an Existing Internship?(Required)

Agency Information

Agency's Name(Required)

Please enter the full name of the agency.

Department(Required)

Please enter the department or unit of the agency where you are interning, if applicable.

Geographical Region of Agency(Required)

Please choose one.

Agency's Address(Required)

Street Address P.O. Box or Suite # City State/Province ZIP / Postal Code

Agency's Phone Number(Required)

Please enter the agency's phone number.

Agency's Website

Please provide the agency's website, if applicable.

Supervisor at the Agency

INSTRUCTIONS: Please list the supervisor at the Internship who provide you with tasks, will complete weekly supervision, complete the visit with you and school faculty to talk about your progress, and complete the student progress evaluation at the end of each semester.

Supervisor's Name(Required)
First Last Suffix

Supervisor's Email(Required)

Supervisor's Phone Number(Required)
Please enter direct line or phone number and extension.

Supervisor's Degree(Required)

Stop! Does the supervisor listed above have a MSW or BSW degree? If yes, go to Memorandum of agreement. If no, please complete the BSW/MSW Consultant information below

BSW/MSW Consultant Information

Instructions: If you have a supervisor without a social work degree at the agency, you must also have a BSW/MSW consultant who will meet with you for additional social work supervision. This means you will have two supervisors - the agency supervisor without a social work degree and the BSW/MSW consultant. Only students without a social worker at the agency will need a BSW/MSW consultant. MSW students will need an MSW consultant; BSW students may have either an BSW or an MSW consultant. The agency either provides the student a BSW/MSW consultant or creates a plan with the School of Social Work to request faculty BSW/MSW consultation, if available. Please list the information about your BSW/MSW consultant here:

Memorandum of Agreement

To determine which memorandum of agreement (MOA) to use, please select one of the following statements:(Required)

Normal Memorandum of Agreement: I am not receiving a stipend or wage for my placement directly from the Agency. I may recieve a stipend from the University of Maine.

Agency Stipend MOA: I am not an employee at my placement. I do receive a stipend from the directly from agency (not the University of Maine).

Employment Based Unpaid MOA: I am an employee at my placement and I am not getting paid for any of my placement hours by the agency

Employment Based Paid MOA: I am an employee at my placement and I am getting paid for all of my placement hours by the agency