Requesting Students:

Agency Field Survey of Learning Opportunities

Please fill out the form and press "SEND" at the bottom of the page.

* indicates required fields
* Name of Agency/Program:
Agency/Program Address:
Agency/Program Zip:
County Served:
Agency Phone:
Agency Fax:
Agency Director:
* Agency Contact Person:
* E-mail Address:
We are accepting students
We cannot accept students at this time

In order to direct students with particular interests, Please check the field(s) of practice that BEST describe your agency. (Check all that apply)

Aging / Gerontology Social Work Rehabilitation
Substance Abuse School Social Work
Criminal Justice / Corrections Homeless
Child Welfare Domestic Violence
Family Services Disabilities
Group Services EAP
Health / Hospital Program Evaluation
Occupational / Industrial Social Work Personnel Management
Mental Health Research
Mental Retardation Legislative
Public Assistance / Welfare Other


Please give a brief description of experiences and specific assignments a student would have in the placement.

Generalist:
Clinical Practice:
Macro Practice:

Help us understand the types of placements that your agency can accept by selecting the types of placements (yes or no) and the number of students for each, below.
[We of course appreciate having some flexibility wherever that is possible].

Generalist
Yes   No #: 1st year MSW (September - May)
Yes   No #: BSSW Undergraduate (September - May)
Clinical
Yes   No #: Advanced Concentration (2nd year) (September-May)
Yes   No #: Block (Summer only – 4 days/week, May - August)
Yes   No #: Advanced Standing (3 Semesters  - June - May)
MACRO (Management)
Yes   No #: Advanced Concentration (2nd year only) (September - May)
Yes   No #: Block (Summer only -- 4 days/week, May-August)
Yes   No #: Advanced Standing (3 semesters, June-May)
 

How many total students can your agency accept?

Are there other requirements about your agency that students should be aware of?  Please check all that apply.

Travel/car required  (non-transport of clients)
Car not required, but highly desirable
Driver’s License Required
Weekend hours available (with LMSW or LCSW supervision)
Evening hours available (with LMSW or LCSW supervision)
Physical Exam Required Paid by Agency
Paid by Student
Handicapped Accessible Elev
Ramp
Bathrooms
Is Paid placement available
(attach additional information)
Yes
No
Is Criminal Background Check/Fingerprinting Required Yes
No
Is Child Abuse Registry Check Required                          Yes
No
Other Requirements
(please explain)

Please list the names of those who will serve as Field Instructors. Indicate whether they would supervise a BSSW, MSW Clinical Practice or MSW Macro Practice student.
(An LMSW plus 2 years experience are required to supervise an MSW student. Field instructors for BSSW students hold a bachelor’s or master’s degree in social work from a CSWE accredited program.)

Field Instructor's Name # 1
Unit Program /Phone # /E-Mail
BSW
MSW
LMSW
LCSW

Type of Student

BSSW   MSW   Macro

Taken SIFI (Seminar in Field Instruction)

Yes   No
 
Field Instructor's Name # 2
Unit Program /Phone # /E-Mail
BSW
MSW
LMSW
LCSW

Type of Student

BSSW   MSW   Macro

Taken SIFI

Yes   No
 
Field Instructor's Name # 3
Unit Program /Phone # /E-Mail
BSW
MSW
LMSW
LCSW

Type of Student

BSSW   MSW   Macro

Taken SIFI

Yes   No
 
Field Instructor's Name # 4
Unit Program /Phone # /E-Mail
BSW
MSW
LMSW
LCSW

Type of Student

BSSW   MSW   Macro

Taken SIFI

Yes   No
 
Field Instructor's Name # 5
Unit Program /Phone # /E-Mail
BSW
MSW
LMSW
LCSW

Type of Student

BSSW   MSW   Macro

Taken SIFI

Yes   No
 
Field Instructor's Name # 6
Unit Program /Phone # /E-Mail
BSW
MSW
LMSW
LCSW

Type of Student

BSSW   MSW   Macro

Taken SIFI

Yes   No
 
Field Instructor's Name # 7
Unit Program /Phone # /E-Mail
BSW
MSW
LMSW
LCSW

Type of Student

BSSW   MSW   Macro

Taken SIFI

Yes   No
 
Field Instructor's Name # 8
Unit Program /Phone # /E-Mail
BSW
MSW
LMSW
LCSW

Type of Student

BSSW   MSW   Macro

Taken SIFI

Yes   No


Thank you.