BackFieldwork forms

    Albany - Field Education Planning and Confirmation Form

    Student to complete and submit to School of Social Work

    Information about student involved

    Student ID Number

    Student First Name

    Student Surname

    Student Contact - Email

    Student Contact - Phone

    Student Address

    Course Number

    Agency Information
    Information about agency and focus of placement

    Agency Name

    'In Work' Placement


    If this is an 'in work' placement, please state how your placement activities will differ from your normal work.

    Focus of Placement

    Start Date

    (dd / mm / yyyy)

    Hours per Week

    Finish Date (approx)

    (dd / mm / yyyy)
    Field Educator Details

    Field Educator/Mentor- Name

    Field Educator - Email

    Field Educator - Phone

    Field Educator - Postal Address

    Agency Physical Address

    Agency Phone Number

    Agency Email

    Field Educator Social Work and/or other professional Qualification (from where):

    Are they a registered Social Worker?


    SWRB registration number

    For in-post placements only - is the Field Educator different from your current supervisor?


    External Supervisor
    Required when placement agency is unable to provide supervision from a Qualified Social Worker

    External Supervisor - Name

    External Supervisor - Email

    External Supervisor - Phone

    External Supervisor - Postal Address

    External Supervisor Social Work and/or other Professional Qualification (from where):

    Are they a registered Social Worker?


    SWRB registration number

    Placement Confirmation

    Has the idea of a placement been informally approved by the placement agency and its management?


    Who should Massey contact to formalise the proposed placement?

    Name

    Phone

    Email

    SWRB Reporting

    What location is the agency in?  These locations are supplied from the SWRB reporting requirements

    Is this a Government Agency?


    What kind of Government Agency is it?  (If applicable)

    If a Government Agency - is the Supervisor registered or not, and on site or not?

    If a Government Agency - is the Secondary Supervisor Registered or not, On-Site or not?

    If this is a Non Government Agency specify if Maori/Iwi based or not.

    If a Non Government Agency please advise if supervisor is a Registered Social Worker or not and on-site or not.

    If a non Government Agency is the Secondary Supervisor Registered or Not, on site or not.

    OFFICE USE ONLY:

    Placement Confirmed by:

    Date

    (dd / mm / yyyy)
    Email Address

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