UM SSW Field Placement
UMB SCHOOL OF SOCIAL WORK FIELD INSTRUCTOR APPLICATION
First Name *
Last Name *
Agency Name *
Address *
City * State * Zip *
Phone *
Fax *
E-mail *
How long have you been
employed at this agency?(years) *
Full Time Part Time(Hours per week) *
What are your days/hours of work?
(Example M-Th, 8am - 6pm) *
Will this be the field instruction site? *
Yes
No
If no, please explain.
Name of your immediate supervisor *
Immediate supervisor email *
Supervisor Title *
Name of agency administrator *
Please note: when you submit this application, your supervisor will be asked to recommend you for this role.
Do you have a MSW *
Yes
No
From what school? *
Year awarded *
Are you an alumnus or alumna of
the UMB School of Social Work?		 Yes No
Do you have at least 3
years post-MSW Social Work Experience? *
Yes
No
Do you currently have a Social Work License? *
Yes
No
From What State? *
License Number *
Have you ever had your
license suspended or revoked? *
Yes
No
If yes, please explain below. *
Do you have any previous experience
as a field instructor
Yes
No
If yes, please indicate below
Academic YearSchoolNo. of Students
  BSWMSW
Will you be providing field instruction
for a student who has applied for
an employment- based placement? *
Yes
No
Please upload Your Resume. *
Upload Resume
Expectations of a Field Instructor
*I have read the " EXPECTATIONS OF A FIELD INSTRUCTOR" and agree to abide by the University of Maryland School of Social Work requirements.>>
Yes
No

Thank You