Practicum Instructor Profile Name* First Last Contact* Business phone Email Internship CoordinatorIf your agency has assigned a coordinator for your field practicum please provide their information. If this person is you, please indicate. Name Business phone Email Agency* Agency Name Title/Position Program Agency Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Practicum/Task InstructorWhich role will you serve for the practicum experience?* Practicum Instructor - HAS A BSW OR MSW AND 2 YEARS POST-DEGREE EXPERIENCE (Practicum Instructors with a Bachelor's degree may only supervise a BSW student) Task Instructor - DOES NOT HAVE A BSW OR MSW OR LESS THAN 2 YEARS EXPERIENCE (Task Instructors have expertise in an area that would benefit the student’s learning goals; however, due to accreditation regulations, they cannot be Practicum Instructors) Are you interested in volunteering to be an offsite Practicum Instructor for the upcoming academic year or in the future?*This is for practicums without a CSWE approved social worker. Offsite Practicum Instructors provide supervision in addition to what occurs at the agency. Contact me for the upcoming academic year Contact me in a future academic year Not interested Do you have a Social Work degree?*Check all that apply Bachelor's in Social Work Master's in Social Work I do not have a Social Work degree Which accredited Social Work Program did you graduate from (Bachelor's degree)?*Bachelor's degree. This information is being collected for purposes of satisfying Council on Social Work Education's (CSWE) verification of degree requirement. By checking this box, I certify that I have graduated from an accredited school of social work.InstitutionDate of completion Which accredited Social Work Program did you graduate from (Master's degree)?*Master's degree. This information is being collected for purposes of satisfying Council on Social Work Education's (CSWE) verification of degree requirement. By checking this box, I certify that I have graduated from an accredited InstitutionDate of completion What is your primary area or specialization in social work practice?*Do you have 2 years of post degree experience* Yes No Do you have a professional license?* Yes No Licensure*LevelState Highest level of education completed* High school/College/University Major Date of completion Have you ever been a Temple University School of Social Work Practicum or Task Instructor* Yes No Please list previous experience (with any school) as a Practicum InstructorAcademic YearSchoolNumber of students Which level of student fits your agency best?*Choose all that apply BSW Generalist MSW Generalist (1st year) MSW Advanced - Clinical MSW Advanced - Macro Practicum/Task Instructor trainingHave you attended the 'Getting Started in the Practicum' seminar with Temple University?* Yes No In which year did you attend the 'Getting Started in the Field' semiar with Temple University?*Have you attended other Practicum/Task Instructor training?Use the + to add additional linesSchool that provided trainingTopicDate Confirmation statement* I confirm that the information given in this form is true, complete and accurate.