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This form is to be completed by Field Education Staff only.
Student ID number
Student First Name/s
Student Contact - Email
Student Contact - Phone
'In Work' Placement
If this is an 'in work' placement, please state how your placement activities will differ from your normal work.
Focus of Placement
Finish Date (approx)
Hours per Week
Field Educator - Name
Field Educator - Email
Field Educator - Phone
Field Educator - Postal Address
Agency Physical Address
Agency Phone Number
Field Educator Social Work and/or other professional Qualification (from where):
Are they a registered Social Worker?
SWRB registration number
For in-post placements only - is the Field Educator different from your current supervisor?
External Supervisor - Name
External Supervisor - Email
External Supervisor - Phone
External Supervisor - Postal Address
External Supervisor Social Work and/or other Professional Qualification (from where):
Has the idea of a placement been informally approved by the placement agency and its management?
Who should Massey contact to formalise the proposed placement?
What location is the agency in? These locations are supplied from the SWRB reporting requirements
Is this a Government Agency?
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.
Placement Confirmed by:
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Last updated on Tuesday 16 August 2016
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