The Chinese University of Hong Kong

THE CHINESE UNIVERSITY OF HONG KONG DEPARMENT OF SOCIAL WORK

Third Exemplary Field Instruction Award for Field Instructors Nomination Form (This form should be completed by the nominator who is not currently supervised by the nominee and returned in confidence to the Department)

Part I Field Instructor to be nominated: (Eng. Name) (Chin. Name)

Part II Particulars of Nominator Name of Nominator: (Eng. Name) (Chin. Name)

(Please tick where appropriate)  Teaching staff member/ field instructor

 Student (who is not currently supervised by the nominee)  MSSc-FT  MSSc-PT  Undergraduate

 Graduate (in recent 3 years)  MSSc-FT  MSSc-PT  Undergraduate Year of graduation:

 Placement Agency Representative Name of agency: Name of unit: Post:

Contact No.: Email Add.: Signature: Date:

Page | 1 Part III (Please use separate sheet if needed) 1. Overall recommendation on the nominee

2. Nominee’s contribution in student fieldwork learning and development:

3. Other comments, if any:

**The nominator should invite the nominee to fill up the “Nominee Information Sheet” in

Page | 2 Attachment 1

**The Selection Panel will also take into consideration the following in selecting the Award recipient: - Field Instruction Team’s recommendation - Immediate past 3 years of Students’ course evaluation on field placement

Part V Declaration of Nominator

I (print name of nominator) have got the consent from the nominee for the nomination. I understand and have no objection that information submitted to the Department of Social Work in connection with the nomination be used primarily for the purpose of assisting the Selection Committee to determine the recipient(s) of the Award.

Signature: Date:

*Completed nomination form should be submitted to Miss Sharon Yip on or before 9 June 2017 via mail or in person to the Department of Social Work (Address: Rm 401, T.C. Cheng Bldg., United College, The Chinese University of Hong Kong).*

Attachment 1

THE CHINESE UNIVERSITY OF HONG KONG DEPARMENT OF SOCIAL WORK

Exemplary Field Instruction Award for Field Instructors 2017 Nominee Information Sheet (This form should be completed by the nominee and returned in confidence to the Department)

Part I Particulars of Nominee Name of the nominee: (Eng. Name) (Chin. Name) Page | 3 Part II (Please use separate sheet if needed) 1. Nominee’s participation in professional development activities

2. Nominee’s participation in external and internal academic/professional/scholarly activities (e.g. conference, research, publication, presentation, etc.)

Page | 4

3. Nominee’s contribution to the Department

4. Other information, if any:

Part III Declaration of Nominee

I (print name of nominee) understand and have no objection that information submitted to the Department of Social Work in connection with the nomination be used primarily for the purpose of assisting the Selection Committee to determine the recipient(s) of the Award.

Signature: Date:

*Completed Attachment 1 “Nominee Information Sheet” should be submitted to Miss Sharon Yip on or before 9 June 2017 via mail or in person to the Department of Social Work (Address: Rm 401, T.C. Cheng Bldg., United College, The Chinese University of Hong Kong).* Page | 5 Page | 6