FACULTY FIELD LIAISON REPORT FORM
The purpose of this form is to provide information to the Field Coordinator regarding student learning
progress in field placement. Please complete this form after each site visit or significant phone/campus
conference and submit it to the Field Coordinator. Thank you!
FACULTY LIAISON:
DATE OF CONTACT: First Visit Second Visit
STUDENT NAME:
BA MSW ILEVEL: MSW II STIPEND/CREDENTIAL: TIVE MH PPS
AGENCY NAME:
FIELD INSTRUCTOR NAME:
Summary of Contact (check all applicable areas):
Reviewed agency orientation and schedule of field placement hours
Reviewed planned learning assignments and congruence with concurrent practice class(es).
Assisted in the development/review of the learning agreement
Reviewed schedule and content of weekly supervision meetings with MSW field instructor/non-
MSW agency supervisor
Discussed current learning progress and identified areas of focus for the remainder of the
semester. Reviewed timelines for completion of learning agreement, evaluation of
practice/journal, and evaluations.
OTHER:
ADDITIONAL COMMENTS AND/OR CONCERNS:
