2023-24 Employment-Based Field Placement Application

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2023-24 Employment-Based Field Placement Application

Department of Social Work (BSW Program)
Kristin Heffernan, Field Coordinator
email: kheffern@brockport.edu

Page 1 of 3 - Part I: Student

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PART I: Completed by the Student
Student Name: Student Name: * First Middle Last
Banner ID *
Must be 9 digits. Currently Entered: 3 digits.
Brockport Email: *
Employer Name: *
Employer Address: Employer Address: *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Employment Start Date: Employment Start Date: * / MM / DD YYYY
List the department, supervisor name, job title, and employment dates for each program in which you have worked for the agency:
Program 1:
Department Name: *
Supervisor: *
Job Title: *
Dates of Employment: *
Program 2:
Department Name:
Supervisor:
Job Title:
Dates of Employment:
Program 3:
Department Name:
Supervisor:
Job Title:
Dates of Employment:
Please provide the following information (required for consideration of approval):
Copy/paste a current job description from your employer: *
2. Briefly describe your current and past job responsibilities at the agency: *
3. Describe the client population and practice methods used in your current job description: *
4. Describe your proposed field placement and indicate why you think it will provide you with new learning opportunities: *
PART II IS TO BE COMPLETED BY THE AGENCY

Agency Contact: Click on the "Continue" button below to proceed to Part II.
Students: Save your work!

1. Check the box next to "Save my progress and resume later".

2. Have you finished your section of this form?
NO -- > Enter your email address.
YES --> Enter your Agency Contact's email address -- NOT YOURS.

3. Click on "Save form and resume later".

4. An email will be sent to your Agency Contact with the subject, "Your attention requested: Field Placement Application".

5. Follow up with the Agency contact to make sure they have received the "Your attention requested" email.
Save my progress and resume later
Enter Your Email Address *

A unique link to resume this form will be sent to the email address entered here.

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Main Page Content

2023-24 Employment-Based Field Placement Application

Page 1 of 3 - Part I: Student

PART I: Completed by the Student

List the department, supervisor name, job title, and employment dates for each program in which you have worked for the agency:

Program 1:

Program 2:

Program 3:

Please provide the following information (required for consideration of approval):

PART II IS TO BE COMPLETED BY THE AGENCY Agency Contact: Click on the "Continue" button below to proceed to Part II.

PART II IS TO BE COMPLETED BY THE AGENCY

Agency Contact: Click on the "Continue" button below to proceed to Part II.