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FIELD EDUCATION AGENCY
ABOUT THE AGENCY:
- Parent Agency Name:______
- Agency Name: ______
- Program Name: ______
- Name of Contact Person______
- Title______
- Address:______
City: ______Zip:______
Phone: ______Fax: ______
E-mail: ______
- Agency Executive, Name(if different from above: ______
Title: ______
- Is your agency a legal entity (governmental or 501© non-profit organization) with authority to provide the social services it is offering? Yes _____ No _____
- Person administratively responsible for field instruction arrangements (if different from contact name above).
Name: ______Title: ______
- If students are assigned to different departments or divisions, please indicate:
______
- Briefly describe agency’s services and attach any approved program descriptions for our files. Attachments cannot substitute description here.
- Please identify specific disadvantaged/oppressed constituencies served by your agency.
ABOUT FIELD EDUCATION:
1. Staff members proposed as field instructors:
(We require that all of the proposed instructors have an MSW degree)*
a.______
(Name)(Location and Phone Number, if different)
b.______
(Name)(Location and Phone Number, if different)
c. ______
(Name)(Location and Phone Number, if different)
2. Student Compensation:
a. Are there stipends currently available for students? Yes _____ No _____
b. If such stipends are available, please indicate amount/frequency______
c. What are the prerequisites/conditions for students to receive stipends at your agency? ______
______
d. Other benefits offered by your agency? ______
3. Student Facilities and Services:
a. Is there a separate student office? Yes _____ No _____
b. Do students share agency staff office space? Yes _____No _____
c. Are private interview facilities available? Yes ____ No _____
4. Student Field Travel (please mark all appropriate items):
a. Public transportation available and possible: Yes _____ No _____
b. Agency car available for students:Yes _____ No _____
c. Agency pays mileage for use of personal cars:Yes _____ No _____
d. Personal car required:Yes _____ No _____
If yes, any specific insurance requirements: ______
5. Please indicate any specials skills that you desire in a student, such as fluency in a
foreign language, sign language, computer literacy, etc.
______
______
6. How many students do you feel your agency can adequately supervise? (We
encourage agencies to develop training opportunities for students (2-4) units.)
______
______
7. What attitudes/aptitudes/characteristics do you consider desirable for students placed in your agency?
8. Are you interested in undergraduate students?Yes______No_____
Are you interested in First-year graduate students? Yes _____ No _____
Are you interested in Second-year graduate students? Yes _____ No _____
Are you interested in training for combination levels (first/second year students)?
Yes _____ No _____
9. Each agency accepting students will be required to participate in a one or two day field orientation training workshop per semester. Would this be a problem for you?
17. If you are submitting this application on behalf of a specific student, do you want the School of Social Work to publicize your information to future students? Yes______No ______
Prepared by ______Date ______
PERSONAL DATA-AGENCY FIELD INSTRUCTOR
Please complete a personal data form for each agency instructor.
1. Name: ______
2. Parent Agency: ______
3. Agency Name: ______
4. Program Name: ______
5. Address: ______City: ______Zip:______
6. Telephone: ______Fax ______
7. E-mail:______
8. Position Title: ______
9. Home Address: ______City ______Zip ______
Telephone(s): ______
ACADEMIC/PROFESSIONAL BACKGROUND
10. Colleges or Universities Attended:
College or University Names: / Dates Attended: / Degree(s) Earned:11. Social Work/Human Services Employment (List most recent first):
Name of Agency: / Address: / From: To: / Position:12. Supervisory Experience (List most recent first):
Name of Agency: / Address: / From: To: / # of Staff:Signature ______Date ______
GRADUATE & UNDERGRADUATE FIELD PLACEMENT
Yes, we would like to have a graduate or/and undergraduate student at our agency:
_____ Social Work with Individuals, Families, and Groups (1st-year student)
_____ Social Work with Individuals, Families, and Groups (Second-year student)
_____ Undergraduate (Senior Year)
As there are many more human services agencies than there are students, we understand that applying with the School of Social Work does not guarantee our agency a student intern unless a student shows interest in our agency.
Name: ______Phone:______
ParentAgency:______
Address: ______City: ______Zip:______
Thank you for completing the application. Please submit your application electronically via email to Field Coordinator: .