аЯрЁБс>ўџ ;=ўџџџ:џџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџьЅСU@ №ПыbjbjЌ›Ќ› 2&ЮёЮёЮџџџџџџˆ˜˜˜˜˜˜˜Ќ8H\$Ќg2ŒŒ"ЎЎЎЎЎЎцшшшшшш$™RыА ˜§ЎЎ§§ ˜˜ЎЎ!iii§˜Ў˜Ўцi§цiiƒb˜˜ЎЎ€ €-бKФ.zц70g‚,›A›ЎЌЌ˜˜˜˜›˜Ў8Ў0о"iсЎЎЎ  ЌЌd SЌЌСёСЋжБВЅ – Division of Social Work Field Instructor Information Form Demographics: Instructor name: ______________________________ Agency name: ________________________________ Phone: _________________ Agency address: __________________________________________________________ E-mail address: _______________________________ Fax: ___________________ Job title: _____________________________________ Full-time ___ Part-time ___ Years of service with agency: ______ Previous field instruction experience? _____ Areas of specialization: ____________________________________________________ Licensed or certified? Yes ___ No ___ Pending ___ Level of licensure / certification and number: _____________________________ Educational Background: Name of graduate school: ____________________________________ Location: _________________________________________________ Area(s) of study: ___________________________________________ Degree: ___________________________ Year of graduation: ________________ (If you attended more than one graduate school, please list others attended on the back of this page). ** ** ** ** ** Name of undergraduate school: _____________________________________ Location: ___________________________________ Major: _________________________ Minor: ________________________ Degree: ________________________ Year of graduation: ______________ Professional Work Experience: (Please begin with position prior to current position) Agency name: ________________________________ Agency address: ______________________________________________________ Job title: _____________________________ Full-time ___ Part-time ___ Length of time with agency: _________ Social work field instruction? ________ ** ** ** ** ** Agency name: _______________________________ Agency address: ______________________________________________________ Job title: ____________________________ Full-time ___ Part-time ___ Length of time with agency: _________ Social work field instruction? ________ Field instructor responsibilities: Your signature below affirms your intention to provide direct supervision for the social work student(s) placed with your agency, and to fulfill the following: Attend program orientation and training sessions offered by the faculty of the Division of Social Work. Be knowledgeable of goals and objectives of the field placement experience and its role in the Bachelor of Arts curriculum for generalist education. Select appropriate assignments and, with the student, create a field placement contract which reflects the learning opportunities and expectations. Provide, for the student, an orientation to your agency and its policies and procedures. Provide a minimum of one hour per week of formal supervision in order to provide the student with feedback and to act as a role model to help the student better understand the role of the professional social worker. Act as a liaison to provide continuity for the student’s professional development in instances where a non-social worker is providing the day-to-day instruction. Participate with the student, the faculty liaison, and/or the director of field placement in evaluating the student’s performance in the practicum. Complete and submit to the faculty liaison and/or director of field placement materials related to the placement – e.g. learning contract, time sheets, evaluations. Notify the faculty liaison and/or director of field placement of any questions or potential problems as they become evident. Signatures: _______________________________________ _________________ (Field instructor) (Date) _______________________________________ _________________ (Non-Social Work supervisor – if applicable) (Date) PAGE  PAGE VIII 45VXfgj я     t Š „ Ё Ђ Ѓ Й К и —,Ь_`rюяё§ЬЭЮЯежзйкрсї№ц№мидимЭиЩиХЩЛДЩДЩДЩХАІŸХ›Х›А›А‘АиŠ€z€zv€z€hi Н hi Н0Jjhi Н0JU hлHGhф"hф"hф"5>*hN) hўJ–5>*hўJ–hўJ–5>*hф" hE"‹hE"‹hE"‹hE"‹5>*hўJ–hE"‹ hнQЗ5>*hлHGhнQЗhнQЗhнQЗ5>*hлHGhлHG5>* hлHG5>*hлHGhлHG5-45WXfg—˜пр+ , u v Ч Ш   i j ž Ÿ э ю я   F їїїїђђђђђђђђђђђђђђђђђђђђђђђђgdлHG$a$gdлHGЮъўўF G ƒ „ Т У t ‰ Š Ю Я § ў ? @ „ к л  QR—˜цчќ)њњњњњњњњњњњњњњњњњњњњњњњњњњњњњgdлHG)*qrЗИ+,ЬЭ56ЫЬ`aКЛ“”67ЫЬqњњњњњњњњњњњњђњђэђшђшђшђшђшђgdN)gdўJ– & FgdўJ–gdлHGqrя№ё§ўџ9XYZ”ЫЬЭЮзийчшщъыњђээээээээээээшшмкимкииш „ќџ„&`#$gdi НgdлHGgdф" & FgdўJ–gdN)схцчщъыєъфрме hлHGhф"hЎYЏhi Н hi Н0Jjhi Н0JUhЎYЏ0JmHnHu0001hP:pi НАа/ Ар=!А"А# $ %Аœ@@ёџ@ NormalCJ_HaJmH sH tH DA@ђџЁD Default Paragraph FontRiѓџГR  Table Normalі4ж l4жaі (kєџС(No List4 @ђ4 i НFooter  ЦрР!.)@Ђ. i Н Page Numberы&џџџџ45WXfg—˜пр+,uvЧШijžŸэюяFGƒ„ТУ  t‰ŠЮЯ§ў?@„кл  QR—˜цчќ)*qrЗИ+,ЬЭ5 6 Ы Ь ` a К Л “ ” 6 7 Ы Ь q r я № ё § ў џ 9XYZ”ЫЬЭЮзийчшщь˜0€€˜0€€˜0€€˜0€€x˜0€€˜0€€x˜0€€x˜0€€x˜0€€˜0€€˜0€€˜0€€˜0€€˜0€€˜0€€˜0€€˜0€€˜0€€x˜0€€x˜0€€˜0€€˜0€€x˜0€€x˜0€€˜0€€x˜0€€˜0€€˜0€€˜0€€x˜0€€˜0€€€˜0€€€˜0€€€˜0€€ €˜0€€ €˜0€€ €˜0€€(˜0€€ €˜0€€€˜0€€˜0€€ €˜0€€ ˜0€€ €˜0€€ ˜0€€ €˜0€€ ˜0€€x˜0€€x˜0€€˜0€€x˜0€€˜0€€˜0€€˜0€€˜0€€˜0€€˜0€€˜0€€˜0€€˜0€€˜0€€x˜0€€˜0€€˜0€€˜0€€x˜0€€˜0€€x˜0€€˜0€€x˜ 0€€˜0€€˜ 0€€˜0€€˜ 0€€˜0€€˜ 0€€˜0€€x˜ 0€€˜0€€˜ 0€€˜0€€ €˜ 0€€˜0€€€˜ 0€€€˜0€€˜ 0€€˜0€€˜0€€x˜0€€˜0€€x˜0€€˜0€€x˜0€€˜0€€˜0€€˜0€€˜0€€˜0€€x˜0€€˜0€€˜@0€€с˜@0€€р {00˜@0€€˜@0€€ {00€›X?0 Ÿœ сы F )qы ъ !•!џ•€џџ Гk ЬŸ+ЁГk Єš+ЂГk Ќ!ьь=*€urn:schemas-microsoft-com:office:smarttags €PlaceName€=*€urn:schemas-microsoft-com:office:smarttags €PlaceType€9*€urn:schemas-microsoft-com:office:smarttags€place€ Ющьэѕd o Ющь335VXfg˜,vij‚Gƒ„ТУ v‰ŠЯл  Qнцщq§,ё § џ YZ–ЮщьЮщьџџgschneidkZ*@h[цѓџџџџџџџџџh„а„˜ўЦа^„а`„˜ўOJQJo(‡hˆHЇ№h„ „˜ўЦ ^„ `„˜ўOJQJ^Jo(‡hˆHoh„p„˜ўЦp^„p`„˜ўOJQJo(‡hˆHЇ№h„@ „˜ўЦ@ ^„@ `„˜ўOJQJo(‡hˆHЗ№h„„˜ўЦ^„`„˜ўOJQJ^Jo(‡hˆHoh„р„˜ўЦр^„р`„˜ўOJQJo(‡hˆHЇ№h„А„˜ўЦА^„А`„˜ўOJQJo(‡hˆHЗ№h„€„˜ўЦ€^„€`„˜ўOJQJ^Jo(‡hˆHoh„P„˜ўЦP^„P`„˜ўOJQJo(‡hˆHЇ№kZ*@џџџџџџџџ         хф"N)лHGE"‹ўJ–ЎYЏнQЗi Нџ@€ЭЭTяЭЭы@@џџUnknownџџџџџџџџџџџџG‡z €џTimes New Roman5€Symbol3& ‡z €џArial;€Wingdings?5 ‡z €џCourier New"ёˆ№аh˜+&ƒвƒІвƒІ?5™ 5™ !№ ДД24ЧЧ3ƒQ№H №џ?фџџџџџџџџџџџџџџџџџџџџџлHGџџ3The University of Memphis  Division of Social Workgschneidgschneid ўџр…ŸђљOhЋ‘+'Гй0А˜ мшќ$ 8D ` l x „˜ Јф4СёСЋжБВЅ – Division of Social Workhe  gschneidrsischschNormald gschneidrsi3chMicrosoft Word 10.0@:Э@†ˆKФ@А?кЩгУ@ŸЯKФ5™ ўџеЭеœ.“—+,љЎ0  hp€ˆ˜  ЈАИ Р фUofMvЧ{ 4СёСЋжБВЅ – Division of Social Work Title ўџџџўџџџ !"#$%&'()ўџџџ+,-./01ўџџџ3456789ўџџџ§џџџ<ўџџџўџџџўџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџRoot Entryџџџџџџџџ РFА*бKФ>€Data џџџџџџџџџџџџ1TableџџџџЋWordDocumentџџџџ2&SummaryInformation(џџџџџџџџџџџџ*DocumentSummaryInformation8џџџџџџџџ2CompObjџџџџџџџџџџџџjџџџџџџџџџџџџўџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџўџ џџџџ РFMicrosoft Word Document MSWordDocWord.Document.8є9Вq