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
2. 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
a) PM Foundation Spring 2012
(These forms are for PM students starting in January 2012)
PM Spring Calendar 2012
Learning Plan
Student Self-Assessment 1st
Student Self-Efficacy 1st
Semester Evaluation SocW570 FI I
Dr. Bennett's Evaluation of Practice Seminar
Evaluation of Practice Proposal
Evaluation of Practice Assignment
Student Self-Assessment 2nd
Student Self-Efficacy 2nd
Semester Evaluation SocW571 FI II
Student Evaluation of Faculty Field Liaison Services
Field Instruction Evaluation of Faculty Field Liaison Services
Student Evaluation of Agency/Field Placement Foundation Year
Liaison Evaluation of Student Evaluation of Practise
b) PM Foundation Summer Block 2012
(These forms are for PM students starting in May 2012)
PM Foundation Summer 2011 Calendar
Learning Plan
Student Self-Assessment 1st
Student Self-Efficacy 1st
Semester Evaluation SocW570 FI I
Dr. Bennett's Evaluation of Practice Seminar
Evaluation of Practice Proposal
Evaluation of Practice Assignment
Student Self-Assessment 2nd
Student Self-Efficacy 2nd
Semester Evaluation SocW571 FI II
Student Evaluation of Faculty Field Liaison Services
Field Instruction Evaluation of Faculty Field Liaison Services
Student Evaluation of Agency/Field Placement Foundation Year
3. Foundation Year Field Forms
Calendar 2011-2012
Learning Plan
Student Self-Assessment 1st
Student Self-Efficacy 1st
Semester Evaluation SocW570 FI I
Dr. Bennett's Evaluation of Practice Seminar
Evaluation of Practice Proposal
Evaluation of Practice Assignment
Student Self-Assessment 2nd
Student Self-Efficacy 2nd
Semester Evaluation SocW571 FI II
Student Evaluation of Faculty Field Liaison Services
Field Instruction Evaluation of Faculty Field Liaison Services
Student Evaluation of Agency/Field Placement Foundation Year
4. Concentration Year Field Forms
a) Child & Family Field Forms
Calendar 2011-2012
Learning Plan
Student Self-Assessment 1st
Student Self-Efficacy 1st
Semester Evaluation SocW572 FI III
Dr. Bennett's Evaluation of Practice Seminar
Evaluation of Practice Proposal
Evaluation of Practice Assignment
Student Self-Assessment 2nd
Student Self-Efficacy 2nd
Semester Evaluation SocW573 FI IV
Student Evaluation of Faculty Field Liaison Services
Field Instruction Evaluation of Faculty Field Liaison Services
Student Evaluation of Agency/Field Placement Concentration Year
b) Community Health & Urban Development Field Forms
Calendar 2011-2012
Learning Plan
Student Self-Assessment 1st
Student Self-Efficacy 1st
Semester Evaluation SocW572 FI III
Dr. Bennett's Evaluation of Practice Seminar
Evaluation of Practice Proposal
Evaluation of Practice Assignment
Student Self-Assessment 2nd
Student Self-Efficacy 2nd
Semester Evaluation SocW573 FI IV
Student Evaluation of Faculty Field Liaison Services
Field Instruction Evaluation of Faculty Field Liaison Services
Student Evaluation of Agency/Field Placement Concentration Year
c) Mental Health Field Forms
Calendar 2011-2012
Learning Schedule
Student Self-Assessment 1st
Student Self-Efficacy 1st
Semester Evaluation SocW572 FI III
Dr. Bennett's Evaluation of Practice Seminar
Evaluation of Practice Proposal
Evaluation of Practice Assignment
Student Self-Assessment 2nd
Student Self-Efficacy 2nd
Semester Evaluation SocW573 FI IV
Student Evaluation of Faculty Field Liaison Services
Field Instruction Evaluation of Faculty Field Liaison Services
Student Evaluation of Agency/Field Placement Concentration Year
d) School Field Forms
Calendar 2011-2012
Learning Plan
Student Self-Assessment 1st
Student Self-Efficacy 1st
Semester Evaluation SocW572 FI III
Dr. Bennett's Evaluation of Practice Seminar
Evaluation of Practice Proposal
Evaluation of Practice Assignment
Student Self-Assessment 2nd
Student Self-Efficacy 2nd
Semester Evaluation SocW573 FI IV
Student Evaluation of Faculty Field Liaison Services
Field Instruction Evaluation of Faculty Field Liaison Services
Student Evaluation of Agency/Field Placement Concentration Year
5. For current foundation year students.
Planning Your MSW Concentration
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
Agency Application Form
Field Instructor Application Form
Agency Update Form
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.
