Downloadable Forms for Students and Field Instructors
All forms submitted must be original. They may be submitted either in person or via mail.
Field Instruction Division
Jane Addams College of Social Work
1040 W. Harrison (M/C 309)
Chicago, IL 60607-7134
1. Electronic field instruction placement forms for Foundation Year and PM students.
These can be completed on a computer, printed for mailing, faxing or sending as an email attachment.
Field Placement Questionnaire for Foundation/1st Year
PM Extended Study Program Foundation Year Field Instruction Questionnaire
Field Instruction Confirmation Form
Liability Insurance Form
(POE) Guidelines & Educational Agreement for Place of Employment Form
Guidelines to using the Learning Plan
2. PM Extended Study Foundation Spring 2013
(For PM Student starting January 2013)
PM Spring 2013 Calendar
Learning Plan
Student Self-Reflection 1st
Evaluation of Practice Proposal
Evaluation of Practice Assignment
Student Self-Reflection 2nd
Student Evaluation of Liaison Services
Field Instructor Evaluation of Liaison Services
Student Evaluation of Agency Field Placement
1st Semester Evaluation PM
2nd Semester Evaluation PM
3. PM Extended Study Foundation Summer 2013
(For PM students starting May 2013)
PM Summer 2013 Calendar
Learning Plan
Practice Evaluation Proposal
Student Self-Reflection 1st
1st Semester Evaluation
Practice Evaluation Assignment
Student Self-Reflection 2nd
2nd Semester Evaluation
Student Evaluation of Liaison Services
Field Instructor Evaluation of Liaison Services
Student Evaluation of Agency/Field Placement
4. PM Extended Study Program 2012-2013 Field Placement Information
PM Extended Study Program Field Placement Information Packet / 1st Year PM students
PM Extended Study Program Field Placement Information Packet / 2nd Year PM students
Prof. Bennett's Evaluation of Practice Assignment Seminar
5. Foundation and Concentration Selections: These are not exhaustive lists of field placement agencies. 6. School Social Work Orientation Forms Criminal Offenses and Background Check
Safety and Technical Standards: Acknowledgment of Capacity for Professional Education and Social Work
United States Citizenship
Agency Information for Prospective Field Placement Agencies
Field Instructor Application Form
Agency Data Form
Task Supervisor Contract
Field forms are also available from the JACSW Office of Field Instruction, fourth floor, ECSW, Jane Addams College of Social Work, Office of Field Instruction, 1040 W. Harrison Street, Chicago, IL 60607.
