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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