Practicum Instructor Profile Name* First Last Contact* Business phone Email Owl News If you would like to receive info about CPH Social Work events, continuing education offerings, and CPH new from TU CPH SSW, use the sign-up link 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?* Field Instructor - HAS A BSW OR MSW AND 2 YEARS POST-DEGREE EXPERIENCE (Field 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 Field Instructors) Are you interested in volunteering to be an offsite Field Instructor for the upcoming academic year or in the future?*This is for field placements without a CSWE approved social worker. Offsite Field 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 Field or Task Instructor* Yes No Please list previous experience (with any school) as a Field InstructorAcademic YearSchoolNumber of students Which level of student fits your agency best?*Choose all that apply BSW Senior MSW Foundation MSW Advanced - Clinical MSW Advanced - Macro Field/Task Instructor trainingHave you attended the 'Getting Started in the Field' 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 Field/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.