Student Field Placement Form

Today's Date*

Student Information

Student's Name*

First Last

Student's Preferred Phone Number*

Student's University of Maine Email Address*

Please enter your University of Maine email only.

Student's Placement Level/Course*

BSW / SWK 495
MSW Generalist / SWK 595
MSW Specialization / SWK 695

Student's Program*

Please choose the program in which you are enrolled.

Online-Blended MSW program
BSW or MSW Campus program

Student's Beginning Semester in Placement*

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

Change in Current Placement?*

Are you completing this form because there is a change in your current placement? This could be any change from correcting an email, to changing a supervisor's name, to changing your placement.

Yes, there is a change in my current placement
No, this is a new placement

Agency Information

Agency's Name*

Please enter the full name of the agency.

Department

Please enter the department of the agency where you are placed, if applicable.

Geographical Region of Agency*

Please choose one.

Agency's Address*

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

Agency's Phone Number*

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 field agency 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*
First Last Suffix

Supervisor's Email*

Supervisor's Phone Number*
Please enter direct line or phone number and extension.

Supervisor's Degree*

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:

Hidden

Site Supervisor's Name
First Last Suffix

Hidden

Site Supervisor's Email

Hidden

Site Supervisor's Phone Number
Please enter direct line or phone number and extension.

BSW/MSW Consultant's Name
First Last Suffix

BSW/MSW Consultant's Email

BSW/MSW Consultant's Phone Number
Please enter direct line or phone number and extension.

BSW/MSW Consultant's Degree

Are you in a Supervision Group at the School of Social Work?
Please indicate if you are in an supervision group at the School of Social Work to get the BSW/MSW consultation. (This group is NOT your SWK 495, 595, or 695 seminar class).

Memorandum of Agreement

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

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.

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

I am an employee at my placement and I am not getting paid for any of my placement hours by the agency

I am an employee at my placement and I am getting paid for all of my placement hours by the agency

School of Social Work

Student Field Placement Information Form

Student Information

Agency Information

Supervisor at the Agency

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

Memorandum of Agreement