FIELD EDUCATION PLACEMENT PLANNING FORM (47-473, 47-475)

The purpose of this form is to compile pertinent information for planning and decision-making
regarding the field placement. When completed, this form will be forwarded to the potential
field site in preparation for the pre-placement interview. A copy will be retained in the
School of Social Work.

This form must be completed and submitted via e-mail to Ms. Leah Cowan,
Undergraduate Secretary, lcowan@uwindsor.ca by Wednesday, March 30th, 2016.

Review the BSW Field Education Manual and the Placement Planning Process at:
http://www.uwindsor.ca/socialwork/bsw/field

Identifying Information
First and Last Name:

Prior Surname (if applicable):

University of Windsor E-mail:

Language Proficiency (other than English):
Current (local) Contact Information
Address:
City:

Province:

Postal Code:

Telephone:
Summer Contact Information (only if different from above)
Address:
City:

Province:

Postal Code:

Telephone:
Previous Education / Experience
Year of High School Graduation:
I have an undergraduate degree/college diploma from:
obtained in (year):
Current Area of Study (please bold): BSW
BSW/Disability Studies

Area of Study:
BSW/Womens Studies

The majority of agencies require students to have a car. Some of our placement sites are outside of
the City of Windsor, so students can be expected to travel, sometimes up to an hour, to get to their
placement. Students are expected to be flexible regarding the geographical area in which they do
their field placement.
I will have use of a car for agency business:

Yes
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No
What skills and knowledge do you bring to the Placement experience? (box will expand as
needed)

What learning needs have you identified as requiring attention in the Placement
experience? (box will expand as needed)

List recent volunteer experience (start with most current box will expand as needed)

List recent employment experience (start with most current box will expand as needed)

Field Placement
List the general goals that you have for your field experience: (box will expand as needed)

Accommodation
The University of Windsor is committed to providing an equitable learning environment that
promotes and supports academic achievement under the provisions of the Ontario Human Rights
Policy. If you believe you (may) require accommodation, please indicate as such and provide
relevant information/data in the space below*

*At the University of Windsor the process for confirming accommodation due to a disability is
undertaken through the Student Disability Services Office to formally confirm the accommodation
request. All students are welcome to discuss their possible need for accommodation with the
Coordinator of Field.

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NOTICE OF DISCLOSURE
CONFIDENTIALITY AND USE OF PERSONAL DATA
The personal information collected on this form is being collected under the authority of the University of Windsor Act, 1962. This collection is compliant with
the Freedom of Information and Protection of Privacy Act of the Province of Ontario.
The purpose of this data collection is related directly to and needed by the School of Social Work, University of Windsor to administer the university / student
relationship including the proper recording of student academic progress and to adhere to governmental reporting requirements.
Data collected on this form will be disclosed and used as follows:
By administrative and field office personnel for student field placement planning and record-keeping;
By field instructors in community agencies for placement planning;
For academic counselling.
If you have any questions about the collection, use, and disclosure of this information please contact: Director of the School of Social Work OR the FIPPA
Coordinator, University of Windsor, 401 Sunset Avenue, Windsor, Ontario, Canada N9B 3P4 (519) 253-3000 ext. 4059. richardt@uwindsor.ca

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