Agency Interest Form

University of Wyoming Division of Social Work Agency Interest Form

Official Agency Name______

Program Name within Agency (as applicable)______

Complete Address: ______Phone number:______

______Fax number:______

______e-mail address:______

Mailing Address (if different):

______Web Site Address:______

______

Executive Director Name and title:______

Initial Contact for Field Placement:______

Check the services provided or administered through your agency as well as populations served:

__AIDS/HIV / __Adult Education / __People on Poverty
__Advocacy / __Intimate Partner Violence / __Policy/ Legislation
__Aging/Gerontology / __Family Services / __Prevention
__Adolescent/Children / __Emergency Assistance / __Public Welfare
__Community Planning / __Gay Lesbian Bi Trans / __Legal Services
__Criminal Justice / __Health Promotion / __Rehabilitation
__Cultural/Ethnic Diversity / __Homeless / __School Social Work
__Disabilities / __Mental Health / __Substance Abuse
__Veterans / __Victim Services

Check what the agency provides for students:

__Desk / __Phone / __Mileage Reimbursement
__Stipend ___ Amount / __ Computer

Stipend Criteria:______

Check what is required from students:

__Background Check (type)______/ __Insurance (type)______
__Immunizations (type) ______/ __Drug Testing
__Language Proficiency other than English / __Specific Training or Courses

Check the appropriate funding source(s) for your agency:

___Non- profit ___Public ___Grant ___For Profit

Does the agency have a specific procedure and or application process in selecting field students and or completing requirements for placement? __Yes __No

If YES, please describe:______

______

Provide a description of your agency and services. In this description include a statement about the agency mission or philosophy. Attach brochures and/or other descriptive materials regarding your agency. The description may be included in our Placement Tracking system so that students may have access to it. You will be able to edit it.

What is your rationale for having social work students placed within your agency? Describe several of the key learning opportunities that students might expect to have within your agency, these may include work with individuals and families, groups, administration, community organization, advocacy, policy, and /or legislation.

Will supervisors be granted comp time or work load adjustment for supervising students? (minimum of 1 to 1 ½ hours of supervision per week) ___Yes ___No

Please List Qualified Potential Field Instructors (must have a Social Work degree)

______

(Name)(Degree)(Years of Post Degree Experience)

______

(Name)(Degree) (Years of Post Degree Experience)

Please list Potential Onsite Supervisors (experienced human service personnel who do not have a degree in social work but would provide field supervision for students if there is not a social work supervisor onsite)

______

(Name)(Degree)(Years of Experience)

______

(Name)(Degree)(Years of Experience)

Enter the number of students your agency can accept for the following categories:

Undergraduate / Graduate
___Fall/Spring (Sept-April; 16 hrs/wk) / ___Fall/Spring(Oct-April; 16 hrs/wk)
___Summer (May-August; 35 hrs/wk) / ___Spring (Jan-April; 34 hrs/wk)
___Summer/Fall (May-Dec; 34hrs/wk
___Fall (Sept-April; 17 hrs/wk)

Person completing form______

Position______Date:______

Field Office: (307)766-2710

Fax: (307) 766-6839

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