MSW Foundation FIELD APPLICATION

AURORA UNIVERSITY

SCHOOL OF SOCIAL WORK

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:

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

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 NO
If 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: ______

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