Forms

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)

Student Emergency Contact

Please list the name and phone number of an emergency contact you give the University and your internship site permission to contact in case of an emergency.

Please select your program, course, and internship semesters from the list below:

Minimum Number of Internship Hours

Beginning semester in internship

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

Choose the option that best describes your internship

Are you completing this form for a new or existing internship?

Agency Information

Full name of agency(Required)

Department, if applicable(Required)

Geographical Region of Agency(Required)

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 (if applicable)

Supervisor at the Agency

INSTRUCTIONS: Please provide the following information about the person at your internship site who will give you tasks, meet with you weekly for supervision, complete the internship visit with you and your faculty liaison to talk about your progress, and complete your 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)

Supervisor's Degree(Required)

Please select the highest degree held

Memorandum of Agreement

Please select the option that best describes your internship to help our Internship Team develop the correct memorandum of agreement (MOA):(Required)

Normal MOA: My internship site is not providing me with a stipend or wage, though I may receive one from the University of Maine.

Agency Stipend MOA: I am not an employee at my internship site, though I do receive a stipend directly from the agency.

Employment Based Unpaid MOA: I am an employee at my internship site and I am not being paid by the site for any of my internship hours.

Employment Based Paid MOA: I am an employee at my internship site and am being paid by the site for all of my internship hours.