Agency/Field Instructor Information (Student: Please complete and return to Seminar Instructor) THIS IS A TYPEABLE DOCUMENT. SAVE this document to your computer. Click on in “View” the upper left corner, then Document” on the dropdown menu. Enter data in the gray “Edit fields. Fields will expand to fit text. Use Tab key to jump to next field. SAVE form as needed. When complete, SAVE again, and print a copy for submission to the Practicum Office. Date: Student WIN: Student level (check one): BSW MSW Clinical MSW Generalist Student Name: Student Phone Number: ( ) Washburn Email: @washburn.edu Seminar Instructor Name: Full Name of Agency: Department within Agency: Agency Mailing Address: City/State/Zip: Field Instructor Name: Phone Number: ( ) Ext: Address: Mailing Address (if different from address above): City/State/Zip: Supervision Day and Time: Do you have a Taskstream account? Preceptor Name: License (check one): LBSW LMSW LSCSW Other Phone Number: ( ) Ext: Email Address: Mailing Address: City/State/Zip: Updated 1-7-19 S:\SocialWork-Administration\Practicum Program\Practicum Forms on the Web
Agency/Field Instructor Information (Student: Please complete and return to Seminar Instructor) THIS IS A TYPEABLE DOCUMENT. SAVE this document to your computer. Click on “View” in the upper left corner, then “Edit Document” on the dropdown menu. Enter data in the gray fields. Fields will expand to fit text. Use Tab key to jump to next field. SAVE form as needed. When complete, SAVE again, and print a copy for submission to the Practicum Office. Date: Student WIN: Student level (check one): BSW MSW Clinical MSW Generalist Student Name: Student Phone Number: ( ) Washburn Email: @washburn.edu Seminar Instructor Name: Full Name of Agency: Department within Agency: Agency Mailing Address: City/State/Zip: Field Instructor Name: Phone Number: ( ) Ext: Address: Mailing Address (if different from address above): City/State/Zip: Supervision Day and Time: Do you have a Taskstream account? Preceptor Name: License (check one): LBSW LMSW LSCSW Other Phone Number: ( ) Ext: Email Address: Mailing Address: City/State/Zip: Updated 1-7-19 S:\SocialWork-Administration\Practicum Program\Practicum Forms on the Web
agency-field-instructor-information-student-input-typeable_72.docx