Self-Referral Form – Office of Practicum Education

Name*
First Last
Pronouns
TU ID*

9 digit number on your Temple University ID badge
Phone*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
TU Email*
Field Internship level*
- BSW Senior year
- MSW Generalist year
- MSW Advanced year
Concentration (advanced year students only)
Campus
- Onsite Program
- Fully Online Program
Agency Information
Date of Interview at Agency*
MM slash DD slash YYYY

Student must have already interviewed and been accepted at this agency in order to submit this application.
Agency Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Practicum and Task Instructor Information
Practicum instructors for baccalaureate students must hold a baccalaureate or master’s degree in social work from a CSWE-accredited program and have 2 years post-social work degree practice experience in social work. Practicum instructors for master’s students must hold a master’s degree in social work from a CSWE-accredited program and have 2 years postmaster’s social work practice experience.
Potential Practicum Instructor's Name*
Email*
Phone*
Does Potential Practicum Instructor have a BSW/MSW?*
- Yes
- No
Specify degree
Date of degree conferral
MM slash DD slash YYYY
Potential Task Instructor's Name

*If applicable*
Email
Phone
Does Potential Task Instructor have a degree?
- Yes
- No
Specify degree
Date of degree conferral
MM slash DD slash YYYY
Date of interview with agency*
MM slash DD slash YYYY
Student Signature

I understand that the Office of Field Education and the agencies that accept students for placement work closely together to provide me with an opportunity to meet the learning objectives of the field instruction

Agency Information

Practicum and Task Instructor Information