California State University, Dominguez Hills

College of Health and Human Services, Human Services Program


Human Services Learning Agreement for Fieldwork Placement 

The purpose of this agreement is to formalize the requirements for students enrolled in a Fieldwork Placement organization.  The Learning Agreement is the cornerstone of the practical experience.  It sets the stage for what happens during the fieldwork placement, from a practice perspective, by providing a guide for the student, the agency-based supervisor, and the Fieldwork Seminar Instructor.  Activities to be performed by the student are to be specified in the space provided.  Activities then lead to skill areas to be learned while doing the specified tasks.  These skills can be specific to the content of the activities, can be personal to the student or can be any combination of the two areas.  There may be skills that are not listed on the Skills Classification List that the student and agency-based supervisor believe are important for the student to learn over the course of the semester.

The student agrees to perform the mutually agreed upon assignments within the agency for _____ hours per week during the current semester in partial fulfillment of requirements for practicum/internship field experience in the Human Services curriculum.

The Fieldwork Supervisor agrees to monitor the performance of the student and to provide direct supervision for a minimum of one (1) hour per week;  and to evaluate the student's overall performance on the Fieldwork Supervisorís Evaluation and Hours Verification form to be provided by the Fieldwork Office.

Student Name___________________________________


Course:   q396/396S (1st sem)    q396/396S (2nd sem)    q496/496S 

Fieldwork Supervisor: _____________________________________

Agency Name: __________________________________

Agency Address: ______________________________________________________

Supervisor Name & Title: ________________________________________________ 

Phone: (      ) ___________________   E-mail address: _________________________

Did you turn in the Fieldwork Placement Form to the Human Services Office?   qYes       qNo
    If No, turn one in immediately to the Fieldwork Office in WH B 385.  A Placement Form  is required every semester.


Learning Objectives & Assignments:
(To be completed by supervisor and student; Add pages as needed.)

   Skills/Learning Objectives 













 This agreement has been read, discussed, and additions have been made by the student, Supervisor, and the Fieldwork Seminar Instructor.  All parties agree to fulfill this Learning Agreement.

______________________________________            _________________________
Student                                                                            Date

______________________________________            _________________________
Agency-based Supervisor                                                Date

______________________________________            _________________________
Fieldwork Seminar Instructor                                            Date