Winthrop University – Department of Social Work
Agency/Field Instructor Report of Field Concerns
Student Name: Date:
Field Agency:
Field Instructor:
Task Instructor (if applicable):
Instructions: Please answer the questions below regarding your current concern(s) related to
your assigned student intern. Once completed, it should be emailed to your assigned Winthrop
field faculty member. He or she will review the concerns presented and initiate a resolution
process/plan, contacting you as needed to gain additional information. Since this report is
initiated by the field instructor/agency, the student will be informed after contact has been made
with the field agency and/or field instructor. However, the student will be notified of the
concern(s) to facilitate a resolution.
1. Please use behavioral terms to describe the area of concern(s) with the student’s
performance in the field.
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2. Describe the behavior(s) expected from the student (in concrete terms) which is to
replace the behavior(s) identified above.
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3. Identify the time frame by which the expected behavior(s) is to occur.
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4. Identify consequences to the student if the desired behavior(s) change does not occur.
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5. Document any previous discussions with the student regarding this issue(s).
Attach any relevant documentation
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