Salisbury University

Salisbury University Social Work Department Employment Based Field Proposal

__ SU Main Campus __Stateside Online __Eastern Shore Higher Ed Ctr __Hagerstown Location __Cecil College __Southern Md Location __ Germany/UMUC/Europe

Name: ______Student ID#: ______

Agency: ______Agency Address:______

Current Supervisor: ______

Proposed Supervisor’s Name: ______

Proposed Supervisor’s email: ______

Proposed Supervisor’s phone: ______

1. Current unit (division or department) within the agency/organization where you are employed, including work assignment:

2. Detail proposed field experience, including work assignment, supervisor and requested reduction in workload:

This proposal must be signed by the following:

Student Date Current Supervisor Date

Proposed Field Instructor Date Agency Executive Date

Please submit this form to your Field Placement Coordinator for approval.

5/17/16 Approved By ______(Salisbury University Field Office)

5/17/16