AGENCY REQUEST FOR STUDENT INTERNS Page 1

CALIFORNIASTATEUNIVERSITY, LONG BEACH

DEPARTMENT OF SOCIAL WORK

REQUEST FOR STUDENT INTERNS

Please PRINT or TYPE your answers. Your completed Agency Information Form will be maintained in our database system.

Today’s Date___/___/___ Agency/Organization:

Address: City State and Zip

Phone #: FAX#:

Contact Person:Phone #:

Other Phone:#Email:

SUMMER BLOCK (SB)Mid May – August 2008.

Children, Youth & Families ONLY

Direct Practice:_____Macro Practice:_____ /

TOTAL SB STUDENTS

_____

ACADEMIC YEAR (AY) September – May 2008-2009.

Children, Youth, & Families (CYF) AND Older Adults & Families (OAF)

CYF

/

OAF

/

TOTAL AY STUDENTS

Direct Practice:
Macro Practice: / Direct Practice:
Macro Practice:

ADVANCED STANDING (AD)June 2008 – May 2009.

Children, Youth, & Families (CYF) AND Older Adults & Families (OAF)

CYF

/

OAF

/

TOTAL AD STUDENTS

Direct Practice:
Macro Practice: / Direct Practice:
Macro Practice:
TOTAL INTERNS REQUESTED

In order for us to more accuratelymatch our students with your agency, please answer the following questions.

1. Briefly describe proposed MSW internship activities in your agency:

2. If internships are available in more than one department/program, please list:

______

DAYS AND HOURS

  1. Does your agency have:

Evening Hours?YesNoIf yes, how late is your agency open?

Weekend Hours? YesNoIf yes, please specify:

  1. Are there specific days that students are required to be in the agency?

Yes_____No_____If yes, please specify:

SPECIAL REQUIREMENTS

  1. Does your agency require:

Special Trainings?YesNoIf yes, please specify:

Orientations? YesNoIf yes, please specify:

If yes for either one, are they held before or after the internship begins?Before_____After_____

  1. Please indicate which of the following your agency requires:

Drug Testing / Physical / Finger Printing/ Live Scan / Other
Background Check / Lab Work / Specific Dress Code

Does your agency cover the cost? Yes___ No___

FINANCIAL ASSISTANCE/STIPEND AVAILABILITY

  1. Does your agency offer any stipends or grants?

Yes_____No_____ If yes, please indicate amount:

If yes, is there an application process, (if yes, please explain)?

FIELD INSTRUCTOR INFORMATION

Basic requirements:

  • Must have an MSW and two years post graduate experience
  • Must have completed or plan to participate in the Field Instructor Training
  • Must provide one hour of individual supervision per week for each student

Please provide the following information for each field instructor:

1.Name and Degree of Field Instructor:

University Attended:Year Graduated:

Phone Number:E-Mail:

FAX:

Field Instructor Training completed at (University)Year

If not complete, indicated where (University) and when you plan to attend:

.

(Please note, you may take the training at any of the local University Social Work Programs)

2.Name and Degree of Field Instructor:

University Attended:Year Graduated:

Phone Number:E-Mail:

FAX:

Field Instructor Training completed at (University)Year

If not complete, indicated where (University) and when you plan to attend:

.

3.Name and Degree of Field Instructor:

University Attended:Year Graduated:

Phone Number:E-Mail:

FAX:

Field Instructor Training completed at (University)Year

If not complete, indicated where (University) and when you plan to attend:

.

PLEASE MAIL OR FAX BY FEBRUARY11, 2008

to

CaliforniaStateUniversity, Long Beach

Department of Social Work

Attention: Traci Jovero

1250 Bellflower Boulevard

Long Beach, CA90840

FAX #: (562) 985-5514

For questions, contact Mike Foster, LCSW

CYF Field Consultant

(562)985-7025

or

Tom Crowe, LCSW

OAF Field Consultant

(562) 985-4647

Mk Request for Student Interns 2007Last updated on 10/13/2018