ࡱ> VXUa bjbj** *JH=bH=bc  8&4Z|'MMM*',',',',',','$)I,P'M+"MMMP'?e'M^8*'M*'V%@"&ЙhBv% '{'0'%T -! -"& -"&MMMMMMMP'P'7MMM'MMMM -MMMMMMMMM B P:  Ƶ SCHOOL OF SOCIAL WORK REQUEST TO USE PLACE OF EMPLOYMENT AS A FIELD PLACEMENT/ OBTAIN EMPLOYMENT AT CURRENT FIELD AGENCY Students currently employed in a social service agency/institution or human service organization may complete their field practicum in their current job only if specific conditions are met. Approval of plans by the Director of Field Placement is required before the start of the practicum. Specific restrictions include, but are not limited to, the following: 1. Students are allowed to use their place of employment as a field placement site but can do so for only one of their two placement experiences, and only if that agency meets all requirements for serving as a placement site (including, in the case of the concentration year, if that agency is suitable for the competencies specific to advanced practice); 2. The field instruction experience must be distinct from the students normal work activities and must be evaluated separately from those activities; 3. The student must be supervised by someone who is not his/her regular work supervisor. This instructor must meet the usual requirements of field instruction i.e., someone who holds a MSW degree with at least 1-2 years of post-graduate experience in the field of social work; 4. The hours credited toward field placement must be distinct from the students employment hours; and 5. Assignment to placement remains solely the province of the programs field director. Ƶ SCHOOL OF SOCIAL WORK Student___________________________________________ Date _______________________________ Email Address ________________________________________________________________________ UM Faculty Liaison ____________________________________________________________________ FIELD PLACEMENT INFORMATION Field Placement Agency _______________________________________________________________ Students Field Placement site (in what Department/Program)___________________________________ Address of Students Field Placement Site __________________________________________________ _____________________________________________________________________________________ Students Agency Field Educator __________________________________________________________ Field Educators Job Title _______________________________________________________________ Field Educators Phone ____________________________ Fax _________________________________ Field Educators E-mail (if available) ______________________________________________________ Students Responsibilities/Assignments in Field Placement (Please include client population and practice methods used in field placement learning experience) ____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Proposed EMPLOYMENT INFORMATION Date student wishes to begin employment at agency ___________________________________________ Agency Department/Program of sought employment __________________________________________ Job Title of sought employment___________________________________________________________ Name of Job Supervisor in Employee role___________________________________________________ Is the Job Supervisor a different person than the Field Educator? Yes_______ No______ Will student continue his or her current field placement as well as seeking employment in another program within the agency? Yes _____ No _____ Employees job duties/responsibilities (Please clearly differentiate from responsibilities as an intern, and specify different client population, practice methods/interventions, etc.) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________  Hours that the student will remain at the agency as an intern and what days/hours that the student will be fulfilling their work responsibilities. The field placement experience must be the primary learning focus. As a MSW InternFall Spring Summer (Circle One)Fall Spring Summer (Circle One)As an EmployeeMondayMondayTuesdayTuesdayWednesdayWednesdayThursdayThursdayFridayFridaySaturdaySaturdaySundaySunday Please return this form with the original signatures of the following persons: the current field educator the student interns proposed work supervisor the student intern the faculty liaison I attest that this proposed employment is different from and will not affect the current field placement. ______________________________________________________________________________ Current Agency Field Instructor Signature Date ______________________________________________________________________________ Student Interns Proposed Work Supervisor Signature Date ______________________________________________________________________________ Student Signature Date ______________________________________________________________________________ Director for MSW Field Education Date Please return this form to: Cherry Malone, LMSW Director - MSW Field Education Ƶ School of Social Work 223 McCord Hall Ƶ, TN 38152 (901) 678-3515      FILENAME \p C:\Users\selswick\Desktop\Request to Accept Employment.doc "23>KVW[ak    xtlalSIhKYB*^JphhKYCJOJQJ^JaJhKYhKYCJaJhKYCJaJhhmhKY5CJaJhKY5CJaJh"5CJaJhmh"5CJaJhi:5CJaJh+'5CJaJhmhve5CJaJ h5 h"CJ hkRCJ h"CJhKYhKY5CJ$aJ$hKYh"5CJ$aJ$hkR5CJ$aJ$ hKY5CJ23W  j     gdKYgd2rgdKYgdKYgdKYgdrl$a$gdo$a$gdrl DE9:mNOFM@Sſ滴 h6>* h">* h"6hI<h6h"hh4E h"5hj h2rh2rh2r hKYCJ hkRCJ hKYCJhKYhKY5CJ$aJ$hkR5CJ$aJ$hKY hrlh"hKYB*CJ^JaJph4 kl9:PQ_`gdh4E$a$gd2rgdKYgdKYTefjkEFTUgdcgdcgd2rgdrlST ]def jk,DOPUku 1ANFMNOϻϷϝϝ hcCJ hcCJhe hy6 he6hve hc>*h hchchyhc h2rCJh2r h"CJhrh" hrl6 hrl6CJh6h">*>NOST $$Ifa$$If $$Ifa$gdygd)gdcgdeKRST(/ek{}")*>?@B\ Ž˧ˣˣ˧˟˛˧hKYh,_Sh#hvehyhh56CJ h5hyh5 h"CJh"h)h)h"CJjh)CJ8UmHnHu hnCJhr hcCJhc;^XMMDD $Ifgda}  !$If$Ifkd$$IfTl4c\^(x*p0`+|4 laf4T NHHH?? $Ifgda}$Ifkd$$IfTlr"*ppp0`+|4 laT)*NHHH?? $Ifgda}$Ifkd$$IfTlr"*ppp0`+|4 laT*+456?@NHHH?? $Ifgda}$Ifkd$$IfTlr"*ppp0`+|4 laT@AHIJQRNHHH?? $Ifgda}$Ifkd$$IfTlr"*ppp0`+|4 laTRS\]^gNCC=4 $Ifgda}$If  !$Ifkd$$IfTlr"*ppp0`+|4 laTghipqryzE???$Ifkd$$IfTlr"*ppp0`+|4 laT $Ifgda}z{}*>NLLDDDD & Fgd)kdn$$IfTlr"*ppp0`+|4 laT>?@23451234*-+,14  "#(.>CFRXioxy}hhihhi0JCJaJ!jhhihhi0JCJUaJh}&hhih jh UhKYhj hKhhkRhyhh3hyh"h#:#>Sj~$a$gd'fgd"q: ! @ ^@ `gdkRĽ h)h"h h}&hhih"hhihi:CJaJ!jhhihhi0JCJUaJhKY0JCJaJmHnHu  !gd)(/ =!"#`$% $$If!vh#v#vp#v:V l4c0`+|,55p5/ / /  / / / 4f4T$$If|!vh#v#vp:V l0`+|,55p/ / / / / / 4T$$If|!vh#v#vp:V l0`+|,55p/ / / / / / 4T$$If|!vh#v#vp:V l0`+|,55p/ / / / / / 4T$$If|!vh#v#vp:V l0`+|,55p/ / / / / / 4T$$If|!vh#v#vp:V l0`+|,55p/ / / / / / 4T$$If|!vh#v#vp:V l0`+|,55p/ / / / / / 4T$$If|!vh#v#vp:V l0`+|,55p/ / / / / / / /  4Ts2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH <`< NormalCJ_HmH sH tH B@B  Heading 1$$@&a$5CJ8@8  Heading 2$@&5>@>  Heading 3$$@&a$5<<  Heading 4$@&5CJDA`D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List 0>@0 Title$a$CJ:J@: Subtitle$a$6CJDCD Body Text Indent ^4@"4 Header  !4 @24 Footer  !.)@A. 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