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Rev.12-2-10 Practicum Guidelines for Non-Social Services Title IV-E Child Welfare Education Program Students

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Page 1: Practicum Guidelines for Non-Social Services Title IV-E ... · Supervisor for the student during their practicum. “Field Program Specialist” the school of social work will have

Rev.12-2-10

Practicum Guidelines for Non-Social Services Title IV-E Child Welfare Education Program Students

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Table of Contents

Introduction …………………………………………………………………….. ii Getting Started …………………………………………………………………. 1 Online Training …………………………………………………………………. 1 Practicum …………………………………………………………………………. 3 Field Activities ……………………………………………………………………. 3 DFCS Online Training Password Request Form ………………………. 3 Keys Assessment ……………………………………………………………….. 4 Transporting Clients …………………………………………………………… 4 Upon Graduation ……………………………………………………………….. 5 Deferment …………………………………………………………………………. 5 Employment ………………………………………………………………………. 5 DFCS IV-E Project Administrators …………………………………………. 6 Attachment A: Sample Checklist (Making Connections) …………… 7 Attachment B: Provisional Certification ………………………………….. 15 Attachment C: Field Supervisor Compensation Forms ……………… 16

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Introduction The Title IV-E Child Welfare Education Program (IV-E Program) is a partnership between the Georgia Department of Human Services (DHS)/Division of Family and Children Services (DFCS) and the participating schools of social work in Georgia. The schools are Albany State University, Clark Atlanta University, Dalton State College, Fort Valley State University, Georgia State University, Kennesaw State University, Savannah State University, Thomas University, University of Georgia, and Valdosta State University. DFCS, through the Education and Training Services (ETS) Section, manages the IV-E Program. Funding for the Program is a combination of Federal money and match from the participating schools of social work. The IV-E Program has several major goals. They are to:

Professionalize the DFCS workforce. Provide degree education for advancement of current staff.

Build a cadre of committed and well-trained staff who are able to assume some of work currently outsourced to other agencies.

The collaboration between the schools of social work and DFCS is very important. The richness of the student’s experience in their field practicum is determined by the strength of this collaboration. The staff in the DFCS county offices are a very important component in this collaboration. They set the tone for the IV-E Program student’s experience at DFCS and the work habits the student internalizes. It is for this reason the Field Practicum Guidelines for Non-Social Services Title IV-E Child Welfare Education Program Students (Guidelines) was written. It is hoped these Guidelines will enhance the field experience for the student and provide guidance for the Field/Task Supervisor. The information included consists of practical guidelines for setting up passwords, getting a transcript, etc. The activities in the Guidelines are found in the DFCS Training and Field Practice Guide. The activities in the Training and Field Practice Guide have been reviewed by the schools of social work and may be used to meet the student’s requirements for their field experience.

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Getting Started Title IV-E Child Welfare Education Program (IV-E Program) students who are not employed by the Division of Family and Children Services (DFCS) in a social services position of Social Services Protect and Placement Specialist (SSPPS; formerly Social Services Case Manager) or higher are required to:

Complete at least one practicum at DFCS. This practicum is to be “in a DFCS office working in direct child welfare service provision.” Please review the Student Agreement section I “Responsibility of IV-E/State Funds Grant Student” paragraph D.

Complete the Online Training and the activities in Training and Field Practice Guide including the Making Connections activities.

The Curriculum Committee of the Education Consortium, composed of the schools of social work, DFCS ETS staff and DFCS county staff, has determined that IV-E students who:

Complete the Online Training, Complete the activities in the Training and Field Practice Guide ( including Making

Connections activities) while doing their practicum in a DFCS county office and

Take the two required Child Welfare courses at their respective school of social work, should be able to take the Keys Assessment and pass it thereby being able to waive New Worker Training. Online Training

Getting the IV-E student enrolled in the Online Training is a two-step process. The Online Training may be accessed at any time from any computer that has Internet access.

Step One (IV-E Program Director) The IV-E Program student must be registered on our Registration and Transcript Center before starting the Online Training. The process is as follows:

The school IV-E Program Director will send a list of the names of IV-E Program students who are ready to start the Online Training to the DFCS Education and Training Services (ETS) Section, Ms. Adell Moore at [email protected]

Note: Please be mindful that the IV-E Program student should not complete the Online Training more than twelve (12) months before graduation. If they complete the Online Training more than twelve months prior to graduation, they will have to take it again once they are hired by DFCS.

Ms. Moore will create an account for the student on the DFCS Registration and Transcript Center.

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She will also obtain an ID and request a password for the student for the Online Training.

On the form for the ID and password, the DFCS county Field/Task Supervisor (if known at the time) will be listed as the student’s Supervisor. The school’s IV-E Program Director or designee will be listed as the Field Program Specialist.

Note –if the name of the Field/Task Supervisor or IV-E Program Director was not entered when the student was registered, their names may be added later. They should access this link https://www.gadfcs.org/ss/tracking/index.html . Complete the form online and then click the submit button at the bottom.

The school of social work’s IV-E Program Director or designee will receive updates from the system on the student’s progress in completing the Online Training. Once the student graduates, the school may contact Athens Tech to have their name removed.

Step Two (IV-E Program Student)

Once the student receives their ID and online password via email, they can begin the Online Training.

They will access the Online Training via this web site https://www.gadfcs.org/training/

The modules in the Online Training are comprised of quizzes and exercises.

*Note-If there are any problems with the Online Training contact Athens Tech via the DFCS Internet Help Desk at 706-355-5144 or [email protected]. The modules IV-E Program Student are required to complete for the Online Training are:

Computer Concepts Introduction to Child Welfare CAPS for Social Services Workers CPS Intake

CPS Investigations CPS Family Preservation Foster Care Intake Foster Care Assessment

Making Connections online activities are listed in the Field Practice Guide which may be downloaded from the Education and Training Services web site: http://www.dfcs.dhr.georgia.gov/portal/site/DHS-DFCS/menuitem.8237042e9dbda3aa50c8798dd03036a0/?vgnextoid=9eb588ad3fdc5110VgnVCM100000bf01010aRCRD&vgnextchannel=6b7f87d3364b0210VgnVCM100000bf01010aRCRD

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If problems arise or there are questions about the Online Training, please contact the DFCS Internet Training Help Desk (located at Athens Tech) at (706) 355-5144 or via email at [email protected]. *The decision was made at an Education Consortium meeting to allow IV-E Program students up to 20 clock hours of field practicum for completion of all of the listed online courses. Please be mindful that completion of the Online Training requires more than 20 hours. Practicum (Internship) Field Activities The goal for the IV-Program student is to complete the field activities during their practicum at DFCS. The Training and Field Practice Guide (including “Making Connections”) is the same document used by new hires at DFCS when they are completing the field practice portion of their training. The Training and Field Practice Guide may be accessed through the Internet by logging onto the following web address: http://dfcs.dhr.georgia.gov/portal/site/DHR-DFCS/menuitem.8237042e9dbda3aa50c8798dd03036a0/?vgnextoid=9eb588ad3fdc5110VgnVCM100000bf01010aRCRD&vgnextchannel=60e529c8facb0110VgnVCM100000bf01010aRCRD alternatively, by going to the DFCS Education and Training Services Section website located at www.dfcs.dhr.georgia.gov/training and:

Click on “Case Managers” then Click on “New Social Services (SS) Case Manager Training” then

Click on “I’m registered, now what?”

On that web page, you will find the modules of the Training and Field Practice Guide. These modules may be downloaded to the student’s Tablet PC, another computer, “thumb” drive, etc. The IV-E Program student is to complete Making Connections (all stages) and modules one (1) through nine (9) of the Training and Field Practice Guide supervised by their Field/Task Supervisor. *Please note those activities that are accessed through the LMS System are not currently available to IV-E Program students. IV-E students will have access to those training activities once they are hired by DFCS. The student needs to ensure that as each activity is completed, the corresponding Checklist is signed. This will verify that the student has completed the activity. The student should keep a copy of each of the signed Master Checklists for themselves, one for their school and one to present to their supervisor when they are hired by DFCS.

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On the page of the Master Checklist that require signatures:

“Trainee” would be where the IV-E Program student signs.

“Field Practice Advisor” would be the individual who served as the Field Instructor or Task Supervisor for the student during their practicum.

“Field Program Specialist” the school of social work will have a designated individual sign.

It is suggested the student also obtain the telephone numbers of the DFCS Field Instructor or the Task Supervisor who supervised them during their practicum. See Attachment A.

The IV-E Program student may also bring a document from their school of social work called a “Learning Plan” or something similar. This document outlines the learning objectives the school wants the student to achieve in their practicum. Many, if not all, of the activities in the DFCS Training and Field Practice Guide may be used to meet the objectives of the student’s learning plan. The IV-E Program student will complete these activities during their practicum (field placement) under the supervision of either a Field Supervisor or a Task Supervisor. A Field Supervisor is an individual with a social work degree and DFCS experience (individuals with a BSW degree may supervise BSW students; individuals with an MSW degree may supervise both BSW and MSW students) who supervises students while they are in practicum. They receive financial compensation from DFCS for being a Field Supervisor. See the forms in Attachment B for Field Supervisors to obtain compensation. A Task Supervisor (has a degree in a field other than social work and/or DFCS experience) may also supervise students during their practicum. When a Task Supervisor is used, the school of social work is required, per the Council on Social Work Education (CSWE), to provide the social work perspective for the students. Once the IV-E student completes all required activities, and passes the Keys Assessment, they are provisionally certified. See Attachment C Provisional Certification information. Keys Assessment The Keys Assessment is usually taken in April for students graduating in the Spring or Summer semester. For those students graduating in the Fall semester the Assessment is usually administered in October or November. There are study guides available on the IV-E Program web site: https://www.gadfcs.org/grant/cwg.jsp The passing score for the Assessment is 85. Please Note: If a IV-E student takes the Keys Assessment as a BSW student and then defers their work obligation to obtain their MSW degree, they will be required to take the Keys Assessment again as an MSW student. Transporting Clients We have checked with our legal department and our risk management unit and IV-E Program students are not covered under DHR’s liability policy for transporting clients. They are not covered under the “Liability Insurance Coverage for Volunteers.” Pages 1.4.1 and 1.4.2 of the

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DHR Risk Management Manual under 3. Exclusions, paragraph g. states” Interns who are receiving a direct benefit from their assignment are not volunteers and therefore not covered under this policy.” The students’ direct benefit is a course grade for their practicum. Therefore, IV-E Program students should not be transporting DFCS clients. If the IV-E Program student has any questions or concerns about their practicum they may address those concerns with their Field Instructor/Task Supervisor, or the IV-E Program Director at their respective school of social work. Upon Graduation Deferment If a IV-E Program student who graduates with B.S.W. degree wishes to defer their work obligation to DFCS to pursue an M.S.W. degree they may do so, provided that the student:

Applies for admission to a participating IV-E school of social work in Georgia Applies for IV-E funds for the M.S.W. degree

Once accepted by the participating school, downloads, completes and faxes the Deferment Agreement found on the IV-E web site: https://www.gadfcs.org/grant/cwg.jsp

Fulfills their work obligation to DFCS once they obtain their M.S.W. degree. Employment Once the non-Social Services IV-E Program student is hired in a social services position the former student, now a IV-E New Hire, and the DFCS county office have some additional tasks to complete. The IV-E New Hire will:

Download and complete the Graduate Information Form found on the IV-E web site: https://www.gadfcs.org/grant/cwg.jsp. Fax the Form along with a copy of their job offer letter to 404-657-4058 to the attention of Ms. Aretha Powell.

Make sure they give their supervisor copies of the signed Master Checklists to verify they completed activities from Making Connections and the Training and Field Practice Guide during their practicum.

Remind their supervisor to merge their transcript under their PeopleSoft Employee ID number

DFCS will:

Request a waiver for the IV-E New Hire by sending the form to DFCS Education and Training Services Section.

If necessary, have the supervisor merge the IV-E Hire’s transcript by: 1. Sending an email to [email protected] with the IV-E Hire’s eight digit ID used

while a student and their PeopleSoft Employee ID asking [email protected] to merge the training information.

Or:

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2. Sending an email to [email protected] stating they are the IV-E Hire’s supervisor and they want to be linked to that person’s account. Once the supervisor is linked to the account, the supervisor may change (merge) ID numbers.

If there are any questions or concerns please contact the IV-E Project Administrators. They are:

Angie Saturday, MS, LMSW, IV-E Project Administrator at (229) 878-8788 or via email at [email protected] for concerns about the following schools or their graduates: Albany State University, Savannah State University, Thomas University, University of Georgia, Valdosta State University

L. Denise Edwards, MSW, IV-E Project Administrator at (404) 550-6822 or via email at [email protected] for concerns about the following schools or their graduates: Clark Atlanta University, Dalton State College, Fort Valley State University, Georgia State University, Kennesaw State University

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Attachment A-Making Connections Checklist-Stage 1

Master Checklist is located in this section and provides a list of the activities to be

completed by Stage. The activity can be downloaded to your tablet from the Education and

Training website: http://www.dfcs.dhr.georgia.gov/training

When possible, the activities should be completed in sequence and within the

required time. In some counties, it may be necessary to complete an activity when

the opportunity presents itself.

CFSR Outcomes and Performance Items have been linked to specific activities.

Supervisors/Training Coordinators should review the CFSR Outcomes and

Performance Items with the trainee to re-enforce the importance.

The Master Checklist will reflect an estimated time to complete each activity. This is

only estimation and times will vary greatly depending on the circumstances.

Supervisor/Training Coordinator should document the actual time each trainee spent

to complete in activity in the far right column. Excessive times should be questioned

and documented to support the Training Time Requirement.

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Stage One: Making Connections in your DFCS Office

Master Checklist

An

ticipated

Ho

urs to

Co

mp

lete

Actu

al Hou

rs to

Co

mp

lete

Date

Co

mp

leted

Day One – Regional Human Resources Orientation 8 hrs

Day Two – County Office

Meet and Greet by the County Director 1 hr

A. Welcome

B. Agency Mission

C. Agency Goal: “Every Child will be safe and thriving

within a forever family sooner”

D. WIG: “No child should be without a permanent family.”

E. CFSR – How one person can impact the results

Preparing the New Employee for Training 1 hr

A. Tablet

B. Passwords

Orientation to the Local DFCS Office 2 hrs

A. Materials to have available

B. New Employee Orientation Checklist

Logistics 2 hr

A. Workstation

B. Tour of DFCS Office

Total Hours for Day Two 8 hrs

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Stage One: Making Connections in your DFCS Office

Master Checklist

An

ticipated

Ho

urs to

Co

mp

lete

Actu

al Hou

rs to

Co

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Date

Co

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Day Three – Training Orientation Activities – WebEx Meeting

Training Introduction 1 hr

A. Trainer Introduction

B. Activity: Class introductions

C. Electronic Participant Guide

D. Training Standards

Tablet 1 hr

A. Tablet Tutorials

B. Computer Security

C. Email Etiquette

Training Overview

A. 3 components of training

B. Training Plan

C. Roles and Responsibilities

Training Sequence

A. Making Connections

B. Keys to Child Welfare

C. Promoting Permanency through Foster Care Services

Course

Tablet 1 hr

A. Tablet Tutorials

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Stage One: Making Connections in your DFCS Office

Master Checklist

An

ticipated

Ho

urs to

Co

mp

lete

Actu

al Hou

rs to

Co

mp

lete

Date

Co

mp

leted

B. Computer Security

C. Email Etiquette

D. Electronic Participant Guide/Ink

Orientation Overview

A. Components of training

B. Roles and Responsibilities

C. Training Sequence

a. Making Connections

b. Keys to Child Welfare

c. Promoting Permanency through Foster Care

Services

d. Strengthening Families to Mitigate Safety and Risk

Factors

D. Certification Process

E. Making Connections – Review of Stages

a. Stage 1 – Making Connection in your county office

b. Making Connections in your Community

c. Stage 3 – Making Connections with the families we

serve

Hyperlinks and Review of Online Training Requirements

1 hr

ODIS

http://www.odis.dhr.state.ga.us/

Education and Training Orientation Series

https://www.gadfcs.org/training/index.jsp

A. How to use the training System

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Stage One: Making Connections in your DFCS Office

Master Checklist

An

ticipated

Ho

urs to

Co

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Actu

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rs to

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Date

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B. Roadmaps to Successfully Online Training

C. New Worker Orientation to DHR and DFCS

D. Introduction to Child Welfare

E. Child Care for Social Services Case Managers

IEP and Educational Services

http://supreme.state.az.us/casa/prepare/training.html

Understanding Substance Use Disorders, Treatment and Family

Recovery: A Guide for Child Welfare Professionals

http://www.ncsacw.samhsa.gov/tutorials/index.asp

The CPS Worker: Making a Case for Safety - Jim Holler

http://www.nationalcac.org/professionals/index.php?option=com_

content&task=view&id=39&Itemid=59

Child Development 101 - Allison DeFelice, PhD

http://www.nationalcac.org/professionals/index.php?option=com_

content&task=view&id=39&Itemid=59

Child Development Activities

http://www.wcwts.wisc.edu/childdevelopment/index.html

The CPS Worker: Making a Case for

http://www.aap.org/family/carseatguide.htm

Review the Department of Justice website and frequently asked

questions at

http://www.djj.state.ga.us/CustomerService/DJJFAQs.shtml

Complete the LMS online course Driver Improvement Program at

http://aging.dhr.georgia.gov/portal/site/DHR-DAS

Complete the Stress Management Course on the LMS website:

http://lms.dhr.state.ga.us/logon.asp

Review the articles on stress at the Help Guide website :

http://www.helpguide.org/

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Stage One: Making Connections in your DFCS Office

Master Checklist

An

ticipated

Ho

urs to

Co

mp

lete

Actu

al Hou

rs to

Co

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lete

Date

Co

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Review the Website for the Division of Mental Health,

Developmental Disabilities and Addictive Diseases.

http://mhddad.dhr.georgia.gov/portal/site/DHR-MHDDAD

Review the GA United Way 211 Directory

United Way of Metropolitan Atlanta

Questions and Answers – Next Steps 15 min

Total Hours for Day 3 4 hrs

Days 4-7

Education and Training Online Orientation Series

https://www.gadfcs.org/training/index.jsp

8 hrs 30

mins

A. How to use the training System

B. Roadmaps to Successfully Online Training

C. New Worker Orientation to DHR and DFCS

D. Introduction to Child Welfare

a. Welcome to DFCS

b. Georgia’s Approach to Child Welfare

c. SCCM Role

d. Course Evaluation

E. Child Care

a. Basic Eligibility

b. Need

c. Communication

d. Final Assessment

e. Course Evaluation

Tablet Tutorials 30

mins

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Stage One: Making Connections in your DFCS Office

Master Checklist

An

ticipated

Ho

urs to

Co

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lete

Actu

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rs to

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Date

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Orientation to Office of Family Independence 4 hrs

A. Complete Temporary Assistance for Needy Families

(TANF) Program Worksheet

B. Complete Child Care Services Worksheet

C. Complete PEACH Care Program Worksheet

D. Complete Food Stamp Program Worksheet

Orientation to Social Services Programs 3hrs

A. Complete Child Protective Services Worksheet

B. Complete Foster Care Services Worksheet

C. Complete Adoption Services Worksheet

D. Complete Resource Development Worksheet

Orientation to Receptionist Duties 4 hrs

Orientation for Regional Accounting 3 hrs

Orientation to Regional Office 3 hrs

Managing Stress 2 hr

A. Review the articles on stress at the Help Guide website :

http://www.helpguide.org/

B. Complete the OHMDR Online course on Stress

Management at http://lms.dhr.state.ga.us/logon.asp

C. Complete Activity Worksheet

Driver Improvement Program 3 hrs

A. Complete the OHMDR Online course

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Stage One: Making Connections in your DFCS Office

Master Checklist

An

ticipated

Ho

urs to

Co

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Actu

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Family-Centered Practice 4 hrs

A. Complete the Family-Centered Worksheet

County Assigned Activity (as needed)

Total Hours for Stage One 56 hrs

Stage One: Making Connections in your DFCS Office

Master Checklist

The trainee has completed all the worksheets, demonstrated satisfactory comprehension of the subject and

received feedback from the supervisor/training coordinator and/or field practice advisor.

________________________________________________________________

Trainee –IV-E Program Student Date

________________________________________________________________

Field Practice Advisor-DFCS Field/Task Supervisor Date

________________________________________________________________

Supervisor/Training Coordinator Date

________________________________________________________________

Field Program Specialist- School of SW IV-E Program Manager Date

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Attachment B

Provisional Certification IV-E new hires who are non-DFCS employees or DFCS employees who were not working in Social Services position prior to being hired/moved to a Social Services position must complete the following during their field practicum in order to be waived from Keys classroom training and be Provisionally Certified upon hiring:

A BSW or MSW Degree from one of the Schools of Social Work that participates in Georgia’s Title IV-E Child Welfare Education Program (IV-E Program).

At least one field practicum at a DFCS county office in social services.

Activities in Making the Connections Checklist (http://www.dfcs.dhr.georgia.gov/DHR-DFCS/DHR_DFCS-Edu/Files/FP-makingconnectionschecklist.doc ).

Education & Training Online courses (all courses, except as noted, may be accessed from this web site: https://www.gadfcs.org/training/)

Introduction to Child Welfare

CAPS for Social Services Workers

CPS Intake

CPS Investigations

CPS Family Preservation

Foster Care Intake

Foster Care Assessment

Field Practice Activities- complete activities in the Field Practice and Training Guide (the Guide may be accessed at this web site: http://dfcs.dhr.georgia.gov/portal/site/DHR-DFCS/menuitem.8237042e9dbda3aa50c8798dd03036a0/?vgnextoid=9eb588ad3fdc5110VgnVCM100000bf01010aRCRD&vgnextchannel=60e529c8facb0110VgnVCM100000bf01010aRCRD

Pass the Keys Assessment with a score of 85% or higher Upon Provisional Certification, the case manager may be assigned a caseload of up to six (6) cases while under direct supervision. Certification: IV-E Graduates from participating Schools of Social Work must complete:

All requirements listed above

Waived from Keys classroom training (2 wks)

CPS Classroom Track (8 days) OR Foster Care Classroom Track (7 days)

CPS GA SHINES Training OR Foster Care GA SHINES Training

Assessment for CPS OR Foster Care with a score of 85% or higher

Certification Field Based Observation conducted by the hiring DFCS office

Certification Record Review conducted by the hiring DFCS office

Certification Decision

*County Director has final decision on granting certification.

Contact Adell Moore at [email protected] regarding certification of your staff.

Attachment C

DFCS Education & Training Services Section

Social Services Protect and Placement Specialist Certification Process

Provisional CertificationCertification for IV-E New Hires

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Department of Human Resources Division of Family and Children Services Steven E. Love, Acting Director

2 Peachtree Street, NW Suite 19-490 Atlanta, Georgia 30303-3142 Phone: 404 651-8409 Fax: 404 657-5105

MEMORANDUM

TO: County Directors of Family and Children Services

DFCS Deputy Directors

DFCS Section Directors

Regional Directors

FROM: Steven E. Love, Acting Director

Division of Family and Children Services

SUBJECT: DFCS process for supervising BSW/MSW interns, pay supplement

DATE: April 29, 2005

Qualified staff persons who provide supervision to Schools of Social Work BSW or MSW interns will be eligible to

receive $ 750.00 for supervising BSW or MSW interns for one full semester. This is a change to the previously

announced 5% pay supplement for staff persons who supervise BSW or MSW interns. The change is effective June

1, 2005.

The Field Supervisor for a BSW intern must either have a BSW degree with five years post-BSW experience or have

a MSW degree with two years post-MSW experience. The Field Supervisor for an MSW intern must have a MSW

degree plus two years of post-MSW experience. County Directors should assure that these requirements are met.

Attached is the “Social Work Field Supervisor Pay Supplement Form”. Part I of this form must be completed,

signed by the county director and sent to the DFCS Education and Training Services Section prior to the beginning of

the internship. Then at the end of the semester, the staff person supervising the interns should complete Part II and

submit the form to regional accounting for payment.

If you have any questions related to this change, please contact Angie Saturday at [email protected].

Thank you.

SEL:as

Attachments

B. J. Walker, Commissioner

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Social Work Field Instructor’s Stipend Payment Form

Instructions: The County Director should complete Part I at the beginning of the internship and fax to Angie Saturday, DFCS Education and Training Services

Section at (404)657-4058. Staff providing field instruction to the interns should complete Part II and submit to Regional Accounting at the completion of the

internship for processing stipend payment. Please note: The stipend amount is $750.00 per semester, no matter how many students are supervised by the

DFCS Field Instructor. We advise that DFCS staff supervise no more than two students per semester.

PART I

County

Student Intern Name Degree student

working toward

(BSW or

MSW)

School of

Social Work

student attends

DFCS Field Instructor Name Field

Instructor’s

Degree

Internship

Start Date

Anticipated

Internship End

Date

DFCS County Director Name:

County Director signature: Date:

PART II

Intern Name Field Instructor Name Actual Internship End Date Stipend Amount Due

Field Instructor’s Name:

Field Instructor’s Signature: Date: