Practicum Instructor Information Form

A qualified Practicum Instructor for the USC Suzanne Dworak-Peck School of Social Work must be an MSW, a graduate of an accredited program who has been practicing for two or more years as an MSW, and be willing to take or has taken a New Field Instructor Training course offered by an accredited university social work program.

* indicates a required field.

First Name

Last Name

Email Address

Agency Name

Business Phone

Fax

Mobile Phone

Street

City

State

ZIP

County

If not Southern California, please provide County

How long have you been at the agency?

MSW School

MSW Degree Year

Are you licensed as a clinical social worker in your state?

YesNo

Are you licensed as a clinical social worker in your state?

If Yes, what year?

List any universities with whom you are or have been a Field Instructor.

Please select any prior teaching experience.

Please select any prior supervisory experience.

Please list any special areas of skill, interest, or expertise.

Please identify personal qualities or limitations that may affect your role as Field Instructor.

What is your typical work schedule? (i.e, nights, weekends, etc)

Have you ever completed a Field Instructor training?

YesNo

If Yes, where did you complete your Field Instructor training?

If Yes, when did you complete your Field Instructor training (MM/DD/YYYY)?

Please upload your resume.

Prior USC Contact (Name of USC employee)