THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL

THE UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL SCHOOL OF SOCIAL WORK 301 Pittsboro Street, Chapel Hill, NC 27599-3550 (919) 962-6442 FIELD INSTRUCTION INFORMATION FORM (Advanced Standing)
The following information helps us determine your eligibility for entering the second-year program and plan your field instruction assignment. Be sure to type your responses. Use extra sheets if additional space is necessary. Request the field instructor(s) or the field instruction coordinator of your undergraduate program, to forward a copy of your field experience evaluation to us prior to your application deadline. Your admissions folder will be incomplete without it. If you are in field placement during the spring semester, request that an interim report be submitted prior to February 15, and a final report, as soon as the field placement is completed.
1.	Name _________________________________________________________________
2.	College education
	Name of College		Dates	Degree	Major
	_______________________________________________________________________ _______________________________________________________________________
3.	Prior paid and/or volunteer social work and related experiences (Begin with most recent position.)
	Name of Agency	Dates	Job Description	M.S.W. Supervision?	Paid or Vol.?
	_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
4.	Identify other life experiences which may contribute to your effectiveness as a professional social worker:
	_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
Field Instruction Information Form Page 2
5.	Describe your undergraduate field instruction experiences
	A. Agency, Address and Phone # _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ B. Type of Assignments _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ C. Types and Number of Clients You Served _______________________________________________________________________ _______________________________________________________________________ D. Social Work Models or Approaches You Used _______________________________________________________________________ _______________________________________________________________________ E. Duration of Placement (Specify # of weeks and # of hours per week) _______________________________________________________________________ _______________________________________________________________________ F. Field Instructor's Name, Social Work Degree and Title _______________________________________________________________________ G. Average Length and Number of Meetings with Field Instructor per Week _______________________________________________________________________
6.	Curriculum concentration you intend to pursue:
	Direct Practice Concentration ____Aging ____Families & Children ____Health & Mental Health Management and Community Practice Concentration ____Aging ____Families & Children ____Health & Mental Health ____Broad-based Human Services