Applicant Information

Full Name: / Date:
Last / First / M.I.
Home
Address:
Street Address / Apartment/Unit #
City / State / ZIP Code
Phone: / () / Home E-mail:

Current Agency

Agency:
Address:
Street Address / Department/Floor/Suite
City / State / ZIP Code
Phone: / () / E-mail Address:
Fax: / ()

Education

Bachelor
University: / Location:
From: / To: / Did you graduate? / YES / NO / Degree:
Masters
University: / Location:
From: / To: / Did you graduate? / YES / NO / Degree:
Ph.D.University: / Location:
From: / To: / Did you graduate? / YES / NO / Degree:
Professional Credentials (Please complete. Check all that apply):
ACSW / LSW / LCSW / PH.D / OTHER (Please Specify)
Please note that an applicant who does not hold a BASW or MSW Degree is required to complete a live or on-line orientation before a student may begin field placement under their supervision.

All of the above sections mustbe completed.

NOTE: Please attach a resume or vita that includes post-master’s training/education (e.g. seminars, continuing education), teaching experience, grants, research and/or publications, memberships in professional societies and professional experience.

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Field Instruction Information

Have you completed a course/training in supervision? / YES / NO
Have you previously been appointed a field instructor at the University of Pittsburgh? / YES / NO
Do you have experience in staff supervision? / YES / NO
I am familiar with the School’s program competencies and related practice behaviors and how to utilize these in my work with students. / YES /
NO
How do you best describe your area of expertise (both skills and field of practice)?
How do you hope to benefit by field instructing a social work student?

References

Please list three professional references who are most familiar with your professional competence, readiness to field instruct and/or supervisor ability.
Full Name: / Position
Agency or Company: / Phone: / ()
Address:
Full Name: / Position
Agency or Company: / Phone: / ()
Address:
Full Name: / Position
Agency or Company: / Phone: / ()
Address:

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.
If this application leads to appointment, I understand that false or misleading information in my application may result in forfeiting this appointment as field instructor faculty for the School of Social Work.
Signature: / Date:

PLEASE MAIL OR FAX THIS APPLICATION TO:

John Dalessandro, Director Field Education
University of Pittsburgh
School of Social Work
2128 Cathedral of Learning
Pittsburgh, PA 15260
FAX: 412-624-6323

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