BSW Student Pre-Placement Interview Outcome Form 2025-26

To be completed by student

Please direct any placement questions to:
Vanessa Peavy, LCSW
Director of Field Education, Department of Social Work
E-mail: vpeavy@brockport.edu

Student Name
Date of Interview Date of Interview / MM / DD YYYY
Agency
Program Name
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Name of person(s) you met with for your pre-placement interview
Summary of pre-placement interview
Outcome of Interview

Outcome of Interview Field placement was offered and accepted Field placement decision is pending Field placement was offered but not accepted by student at time of this report Field placement offer declined by agency (describe reasons)
If decision is pending, please provide reason or next steps planned (e.g. second interview, awaiting agency decision, etc.)
A student is expected to accept a placement assignment. In rare instances, a student is permitted to decline a field placement assignment for compelling reasons. Please list the reasons below and immediately contact the GRC Field Education Office to discuss concerns
Please describe reasons that field placement was declined by agency
By entering name and signing below I, the student, confirms that all the responses are truthful.
Draw your signature into the box below.

Draw or Type

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Full Name

I understand this is a legal representation of my signature.