Field Instructor Experience 1. Overview Questions Question Title * 1. Please fill out your information Name: Agency: Address: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code: Country: Email Address: Phone Number: Question Title * 2. Select one: Task Supervisor (MSW) Field Instructor (BSW) Field Instructor Question Title * 3. Name of Student Intern: Name: Name: Question Title * 4. Student is BSW MSW Foundation MSW Advanced Standing/Second Year Question Title * 5. I attended the Field Instructor training at the beginning of the year. Yes No Question Title * 6. I submitted my resume to the field director. Yes No (please submit to racovita@andrews.edu) Question Title * 7. Learning Plan activities assigned to the student were clearly linked to Practice Behaviors? Yes If no please explain below: Question Title * 8. Learning plan activites seemed congruent with the educational level of the student? Yes No Next