AURORA UNIVERSITY
SCHOOL OF SOCIAL WORK
MSW Foundation FIELD APPLICATION
INSTRUCTIONS:This form is to be completed by the student when there is an agreement with an agency about initiation of a field placement. Submit form via mail or email to:
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Dan Knapp
Director of Field Instruction
347 South Gladstone Avenue
Aurora, IL 60506
Date of Application: ______
** Note, failing to answer any question will result in an incomplete application
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NOTE: YOU CANNOT BEGIN THIS INTERNSHIP UNTIL THIS FORM IS COMPLETED BY STUDENT, APPROVED BY THE DIRECTOR OF FIELD INSTRUCTION, AND YOU RECEIVE A CONFIRMATION LETTER.
Student______
LastFirstPhone (H/C)
______
Home Address
Student ID______AU Email: ______
Are you seeking this placement to count towards one of AU’s MSW specializations? YES or NOIf so, select the specialization below.
Addictions / Child Welfare / Faith-Based / Forensics
* See page 4 for Eligibility Requirements
FIELD AGENCY INFORMATION
()
AGENCY/SCHOOL NAMEDISTRICT #AGENCY PHONE
STREETCITYSTATEZIP
(MUST BE A STREET ADDRESS NOT A PO BOX)
Field Instructor/Supervisor (MSW) ______Phone: (___)______
(Supervisor must have CADC for addictions placement and Schools Certification for schools placements)
Field Instructor Email: ______
Other personnel involved with field instruction on site: Name: ______
Phone: ______
Will placement begin early (before the semester begins)? ____Yes ____ No
PLACEMENT BEGINS _____/_____/_____ ENDS _____/_____/_____ (please indicate Month, Day, Year)
Previous Experience
Please attach a resume to this application. Reviewing your experience in the field of social work is essential to ensure your field placement will provide a robust experience.
Is this field placement your place of employment OR a second placement within the same field agency? ____Yes ____ No (if Yes- an additional JAFP form is needed before placement is approved – please contact the field office for this form)
Schedule Commitment for Field Placement
Below please provide the beginning and end time of your internship shift for each weekday (i.e., 8-4, AND n/a on days you will not intern). Once this application is signed, any changes must be communicated to the field office prior to changes being implemented. The plan should encompass your ability to secure 300 field hours each semester (on average 20 – 24 field hours weekly).
Mon: ______Tues: ______Wed: ______Thurs: ______Fri: ______
Sat: ______Sun: ______Total weekly field hours: ______
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What day will 1 hour weekly supervision occur and how (i.e., individual, group, etc.)? ______
______
( *** note, department meetings do not count towards the 1 hour requirement)
Interview Questions
Please discuss EACH of these questions below during your interview. Mark ‘yes’ or ‘no’ for each question and do not leave blank.
______Does the agency mandate any pre-screening requirements to be completed PRIOR to you starting your placement (i.e., background check, drug test, medical insurance, car insurance, cpr, cpi, TB test, etc.)?
( *** AU is legally bound to agencies to ensure compliance with these requirements and you must complete these requirements and send results to AU field office prior to starting your placement).
______Will you be responsible for transporting clients OR conducting home visits? ( *** If the answer is yes and you are unwilling to complete this task, you will need to decline this internship at the interview and find a new placement).
______Will the agency provide reimbursement for gas or cell phone use?
______Is training provided for personal safety issues, such as home visits, dealing with hostile clients, etc.?
______Expectations about dress code, agency paperwork, and agency policy were reviewed
SPECIAL ISSUES OR CONCERNS
Have you (student) ever been convicted of a felony? If so, please explain: ______
______
Have you (student) ever been convicted of a misdemeanor involving domestic violence or the maltreatment of a child or an elderly person? If so, please explain: ______
______
Does this placement involve any conflict of interest for the student or supervisor? (e.g. have you worked here, student received services as client of agency/supervisor, student’s family member employed at agency/school):
If you have any issues or concerns that may have a direct impact on your field placement, please contact the Director of Field Instruction immediately 630-947-8936. These issues include but are not limited to issues such as substance abuse recovery and mental health concerns. Providing this information will assist the Director of Field Instructor in assisting you in finding a placement that you find comfortable. Information provided will be treated confidentially. The field office CANNOT guarantee an agency will allow you to return to the internship if these concerns are discussed AFTER you start your placement.
Please Indicate (by placing an ‘x’) the overall Type of Placement. Select no more than 2
1_____ Addictions2_____ Administration
3_____ Advocacy4_____ Aging/Gerontology Social Work
5_____ Child welfare6_____ Community Development
7_____ Community Mental Health8_____ Corrections/Criminal Justice
9_____ Developmental Disabilities10_____ Displaced persons / homeless
11_____ Domestic violence / violence 12_____ Family Services
13_____ Global / International Social Work 14_____ Health / Integrative Health or Mental Health
15_____ Immigrant / Refugee Work16_____LGBTQ
17_____ Military Social Work18_____ Occupational or rehabilitation Social Work
19_____ PTSD / Veterans20_____ Program Evaluation
21_____ Public Assistance / Public Welfare22_____ School Social Work
23_____ Social Policy24_____ Other: ______
GENERAL REQUIREMENTS
Please read carefully and indicate awareness of responsibilities with your signature and date.
* I understand that the Field Manual is the “textbook” for my field placement. I also understand it is my responsibility to download and understand this manual. This manual is located on Aurora University website Additional forms and instructions will be indicated on Moodle page for this course.
* I understand that my field placement is for two consecutive semesters (unless otherwise arranged; PEL: Social Work; Summer Block; Early Start). If there are issues that arise which will effect my continued placement I will contact my Field Liaison or the Director of Field Instruction immediately.
* I understand that failure to submit my semester evaluations or x-grade forms can result in receiving no credit for my field experience and prolong my academic involvement in school.
* I understand that I must treat my field placement in a professional manner which will include, notification of absences or being late to my field instructor or agency/school supervisor, dressing in an appropriate manner for my placement, being knowledgeable about agency/school policies, etc.
* I understand that the field experience continues until I’ve reached the mutually agreed upon end date and goals for completion that were created with my field supervisor and the host agency, and this could result is me accruing more hours than the required minimum amount.
* I understand that I am not permitted to terminate the field placement; I need to notify my Field Liaison or the Director of Field Instruction if problems occur.
* I understand I may not begin my Field Placement hours until I receive a confirmation letter from the Director of Field Instruction.
______
Student Signature (Required)Date
--- After approval, revisions to this document must be communicated with the liaison and written approval of changes must occur through the liaisons and/or Director of Field – or, will otherwise be invalid
______
Field Instructor/Supervisor Signature (required)Date
*** An AU-agency legal affiliation agreement is now required for all agencies and a student cannot start their placement until this is completed. Our team will reach out to you shortly if there is no agreement OR if a prior agreement expired.
______
Director of Field Program SignatureDate
ELIGIBILITY REQUIREMENTS THAT MUST BE SATISFIED IF USING THE INTERNSHIP TO COUNT TOWARDS A SPECIALIZATION
ACSWS (Advanced students only): Agency must provide in-depth psychotherapy opportunities where a client is being treated for months (hospital and crisis intervention agencies do not qualify);
Addictions: Agency must be DASA certified, supervisor holds their CADC, and treats addictions;
Child Welfare: Agency offers opportunities to work with families facing turmoil and struggles while protecting children from abuse;
Faith Based: Agency offers opportunities to reflect on how spirituality impacts client development;
Healthcare (Advanced students only. See healthcare coordinator if a foundation student): Agency offers opportunities to think from a system perspective to determine how even the best agency environment can be enhanced by change, reflect on own lifestyle choices that impact health;
Gerontology(Advanced students only. See healthcare coordinator if a foundation student): Agency offers opportunities to think from a system perspective to determine how even the best agency environment can be enhanced by change, reflect on own lifestyle choices that impact health;
PEL School Social Work (Advanced students only): Intern in a school under a type 73 or PEL licensed clinician;
Leadership: Agency offers administrative tasks, board meetings or grant writing;
Forensics: Agency offers opportunities to work with the court and/or legal system
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