About this form: 

This form is designed to be completed when a student is working with a field instructor who has not worked with your program before. In such a case, this form would be used to establish the dates of supervision during which the student will be working with the field instructor as well as ensuring that the supervisor is a qualified field instructor. 

This form is completed and signed by the field instructor, then signed by the student, and then signed by the Placement Coordinator so that all three individuals can review and approve the information provided.