University of Houston
University of Houston Graduate College of Social Work
Office of Field Education (713) 743-8088(off); (713) 743-8014(FAX)
FIELD INSTRUCTOR APPLICATION
Name:
Title: Length of Employment:
Agency Name:
Agency Address:
Agency Phone:
E-mail Address:
DEGREES
Bachelor’s: Date:
University:
Master’s: Date:
University:
LICENSE TYPE:
PREVIOUS SOCIAL WORK EMPLOYMENT – If less than 2 years at current employment, list:
Agency Dates
1.
2.
3.
Do you speak a second language? yes no
If so, which language(s)?
Have you attended the Field Instructor’s Training Seminar taught by the UH-GSSW Office of Field Education? yes no Date:
Are you able to provide at least one hour per week of individual supervision to each assigned student? yes no
PLEASE EMAIL THIS FORM, ALONG WITH A COPY OF YOUR OWN RESUME OR VITA, TO:
jfluelle@central.uh.edu
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