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Posted: December 21st, 2022
Initial Statement of Placement / Learning Contract: This form summarizes the roles, responsibilities you will perform, and goals you will accomplish at your field placement as negotiated and agreed upon by you and your field supervisor. Signatures from you and your field supervisor on the form are required before this document is considered complete.The form must be uploaded into the course must be submitted prior to the start of any practicum hours and before the end of week three.HSV:
HUMAN SERVICES FIELD PRACTICUM I & II
Initial
Statement of Placement and Learning Contract
Directions:Field
practicum students should meet with their field supervisor to fill outthis
form. Items marked with an asterisk (*) should be filled out with
your field supervisor and will serve as the basis of your learning
contract with your host organization. Please fill out this form completely
before handing it in.
*Supervisors
please note that we ask you to:
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Scheduleone supervisory
session per week.
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Make availablean adequate work
area for students to complete the tasks assigned.
*Should you desire to keep this student for an
additional semester, new objectives must be created and identified.
Mid and End of the Semester Evaluations
Lastly, we ask that you assist in the evaluation
of the studentâs performance. At the end of the studentâs assignment we will
send you an evaluation form to be completed on behalf of the student. The
student will also be asked to complete an evaluation of their practicum
experience upon completion of their assignment.
Student
name:
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Name of
organization/agency hosting your placement:
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*
Start date of field placement: *
Anticipated end date of field placement:
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Briefly
describe (in the box provided below) the organization/agency including
location, setting (e.g., mental health center), services provided (e.g., crisis
intervention, parent counseling), populations served (e.g., elderly, inner city
pre-school children):
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* Name of
the position you will be assigned to (e.g., case manager):
* State your
schedule, hours per week, and pay rate:
* Describe
the roles, responsibilities, learning experiences, projects and clients you
will be assigned to:
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* Name and
title of your field supervisor:
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Telephone
number, email address, and address of your field supervisor:
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*
Hours per week you will be meeting with your field supervisor, one-on-one to
discuss your work and receive direct supervision:
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List and describe your previous field
practicum placements and/or employment in the field of human services:
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Given
your description above of the roles and responsibilities you will be
fulfilling, list and describe your personal and professional strengths:
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* Given your description above of the
roles and responsibilities you will be fulfilling, list and describe your most
important areas of need or in other words, what kind of assistance will you need
most from your field supervisor:
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*
Learning Goals and Activities:Please state 3â
5 Learning Goals (i.e., what youhope to learn from this experience)
and the Learning Activities that will provide you the opportunity to achieve
these goals (e.g., to develop verbal and non-verbal communication skills
involved with facilitating group work, / to conduct a comprehensive intake
assessment).
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Learning Goals
Learning Activities
1.
2.
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3.
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4.
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5.
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Student signature:
Date:
Supervisor
signature:
Date:
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