University of Pittsburgh � School of Social Work � Field Education - Download Now DOC

							                               UNIVERSITY OF PITTSBURGH - SCHOOL OF SOCIAL WORK – FIELD EDUCATION

                                       MSW FIELD PLACEMENT CONFIRMATION FORM
The signed confirmation form must be received for a field placement to be confirmed; when sent electronically a digital signature is
acceptable. A confirmation letter will be issued after receipt of the confirmation form.

                                                       Please identify field advisor who referred student:
                                                                                                                                Kathleen                 Laura Perry
    John Dalessandro              Amy DeGurian              Stephanie Eckstrom                  Paul Kowatch
                                                                                                                             McDonough                Thompson
dalessan@pitt.edu              aad62@pitt.edu            sae102@pitt.edu                     pkssw@pitt.edu
                                                                                                                             kemst34@pitt.edu         lpt@pitt.edu
   Deborah Robinson               Bobby Simmons
drc16@pitt.edu                   bobby@pitt.edu
                                                       TO BE COMPLETED BY THE STUDENT
Last Name:                                                            First:                                   Middle:
                                                                                                                                                      Miss   Mrs.        Ms.    Mr.
                                                                                                               Work
Home Phone :      (        )                              Cell Phone:           (        )                                      (        )
                                                                                                               phone:
Mailing
                                                                                             City/State/Zip:
Address:
                                                                   PLEASE COMPLETE ALL THAT APPLY:

I have interviewed with                                  at                (Agency/Organization) and will accept this agency and field
                                                                                                                                                                   Yes          No
instructor for a field placement.
I have interviewed with                                  at            (Agency/Organization) and I wish to discuss the interview further.
                                                                                                                                                                   Yes          No
Please call me at: (        )
A stipend has been offered to me in the amount of $                                                                                                                Yes          No
                                                                     If yes, please compete the following:
Are you an employee here?                        Yes          No
                                                                     Occupation/Title:

Student Placement Location (if different from above information):

Student Signature:                                                                                                                                      Date:

                                              TO BE COMPLETED BY THE FIELD INSTRUCTOR
Last Name:                                                            First:                                   Middle:
                                                                                                                                                       Dr.   Mrs.        Ms.    Mr.
Degree Credentials:                                                            Phone:         (       )                         Email:

Organization/Agency:                                                                                           Department:

Organization/Agency Mailing Address (Street/Building/Floor/Suite):

City/State/Zip:

I will accept the above mentioned student for placement?                                                                                                         Yes           No

I wish to discuss the interview further. Please call me at: (             )                                                                                      Yes           No
Will a Task Supervisor be assigned? For more information on field supervision please see:
                                                                                                                                                                 Yes           No
http://www.socialwork.pitt.edu/academic-programs/field-education/field-instructor.php
Name of Task Supervisor
                                                                      Phone Number:       (                        )                     Email:
(If applicable):

Field Instructor Signature:                                                                                                                             Date:

Comments (if any):


                                                   TO BE COMPLETED BY THE FIELD ADVISOR
    MSW – Full-Time            MSW - Part-Time           MSW - Advanced Standing
                                                                                                          HSV            CWEL       HPPAE         Joint Degree         MH Cert.
 Concentration:                Direct Practice         COSA                         Foundation
                                                                                                          Gerontology Cert          Human Svc. Mgmt. Cert.              CYF Cert
    Fall 2012           Spring 2013              Summer 2013

Field Advisor Signature:                                                                                                                                Date:


                                    Completed application should be faxed to: 412-624-2977, or emailed to the Field Advisor named above.
                                                                                                                                                  Revised: 11/6/2012