<p> Salisbury University Social Work Department Employment Based Field Proposal</p><p>__ SU Main Campus __Stateside Online __Eastern Shore Higher Ed Ctr __Hagerstown Location __Cecil College __Southern Md Location __ Germany/UMUC/Europe</p><p>Name: ______Student ID#: ______</p><p>Agency: ______Agency Address:______</p><p>Current Supervisor: ______</p><p>Proposed Supervisor’s Name: ______</p><p>Proposed Supervisor’s email: ______</p><p>Proposed Supervisor’s phone: ______</p><p>1. Current unit (division or department) within the agency/organization where you are employed, including work assignment:</p><p>2. Detail proposed field experience, including work assignment, supervisor and requested reduction in workload:</p><p>This proposal must be signed by the following:</p><p>Student Date Current Supervisor Date</p><p>Proposed Field Instructor Date Agency Executive Date</p><p>Please submit this form to your Field Placement Coordinator for approval.</p><p>5/17/16 Approved By ______(Salisbury University Field Office)</p><p>5/17/16</p>