For MSW Students Only
Plan for field internship hours/assignments over winter break. Submit for approval by December 9, 2016
Student’s Name: Campus Email:
Field Placement:
CHECK ONE: NEED TO MAKE UP HOURS (specify how many hours needed): ______________________________
HOURS FOR CONTINUITY (IN EXCESS OF REQUIRED NUMBER)
Total number of hours over break proposed (Maximum of 16 hours per week allowed): __________________________________
WINTER RECESS 16-17
Please use the calendar below to enter the proposed hours each day, e.g., 1 PM-5 PM (4 hr):
12/24 – 1/2: WINTER RECESS; UNIVERSITY IS CLOSED AND NO STUDENTS MAY BE IN FIELD
Holiday-No Field
Holiday-No Field
Instruction Begins
I agree to the above plan: ________________________________________________________________________________
Student Signature Date
Request for Make-up Hours: I confirm that student has completed 2/3 of hours/assignments satisfactorily AND/OR has faced
exceptional circumstances (documented in the field liaison reports) that warrant approval of the above plan.
Approved by: ___________________________________________ ____________________________
Field instructor/Supervisor Date
Approved by: ___________________________________________ ____________________________
Field Liaison Date
Approved by: ___________________________________________ _____________________________
Field Coordinator Date
Rev. 10/24/16
