PNth Field Education Planning and Confirmation Form

Information about student involved

Student ID number

Student First Name/s

Student Surname

Student Contact - Email

Student Contact - Phone

Course Number

Agency Information

Information about agency and focus of placement

Agency Name

'In Work' Placement

Yes
No

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)

Finish Date (approx)

(dd / mm / yyyy)

Hours per Week

Field Educator Details

Field Educator - 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?

Yes
No

SWRB registration number

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

Yes
No

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?

Yes
No

SWRB registration number

Placement Confirmation

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

Yes
No

Who should Massey contact to formalise the proposed placement?

Name

Phone

SWRB Reporting

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

Is this a Government Agency?

Yes
No

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

Email Address

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PNth - Field Education Planning and Confirmation Form