FIELD EDUCATION PROGRAM

Participant Agreement

IDENTIFYING INFORMATION
Name: / Email: / Work Site(s):
Work Phone #: / Cell Phone# / PSA Coordinator

MY EDUCATIONAL BACKGROUND IS: p Social Work p Counseling p Other ______

I AM INTERESTED IN BEING A: (CHECK ALL THAT APPLY)

o  Field Instructor: Field Instructors are responsible for the training and supervision of assigned intern(s). They facilitate the placement experience, assess student competencies, and evaluate the intern’s professional development.

o  Preceptor: Under the direction of the Intern’s Field Instructor, Preceptors take responsibility for a piece of the student’s learning, often teaching a specific area of expertise or skill. Pupil Services Counselors may precept for fellow PSA, SMH, or School Counseling colleagues.

FIELD INSTRUCTOR ELIGIBLITY FOR FIRST OR SECOND YEAR SOCIAL WORK (MSW) INTERNS:

1.  Must have an MSW degree from an accredited school in Social Work (Please Note: Per CSWE Standards, an MSW is required for social work graduate level interns)

2.  Must have a Pupil Personnel Services Credential (PPSC) in School Social Work AND Child Welfare and Attendance

3.  Must have a minimum two years of experience as a Counselor for Pupil Services

4.  Must have/will complete the mandatory course for new field instructors offered through one of the graduate social work programs

FIELD INSTRUCTOR ELIGIBLITY FOR COUNSELING INTERNS:

1.  Must have an MSW degree from an accredited school in Social Work OR MA in School Counseling

2.  Must have a Pupil Personnel Services Credential (PPSC) in School Social Work or School Counseling AND Child Welfare and Attendance

3.  Must have a minimum two years of experience as a Counselor for Pupil Services

PRECEPTOR ELIGIBILITY FOR CHILD WELFARE AND ATTENDANCE (CWA) INTERNS:

1.  Must have an MSW degree from an accredited school in Social Work OR MA in School Counseling

2.  Must have a Pupil Personnel Services Credential (PPSC) in School Social Work OR School Counseling, AND Child Welfare and Attendance Credential

EXPERIENCE
I have previously served as a Field Instructor: p Yes p No / If yes, how many years total?
I have previously served as a Preceptor: p Yes p No / If yes, how many years total?
SOCIAL WORK ONLY
I have completed Social Work Field Instructor/Preceptor Training: p Yes p No
I Plan to Complete the Field Instructor/Preceptor Training: When? / Where?
INTERNS
Please list the number of interns you will be willing to supervise for the 2015-16 school year:
Please list the number of interns you will be willing to precept for the 2015-16 school year:
INTERN NAME(S) / UNIVERSITY / GRADUATE PROGRAM / YEAR / FIELD LIAISON

(If Applicable) Name AND Unit of Field Instructor you are precepting for:

FIELD INSTRUCTOR NAME / UNIT

All interns must be processed as an LAUSD School Volunteer prior to the commencement of their field assignment:

·  An LAUSD Volunteer Application accompanied with proof of TB Clearance must be submitted for each intern to Central Leads

·  Each intern must have LAUSD Fingerprint Clearance and Megan’s Law/Sex Offender Clearance

·  Central Leads will be responsible for ensuring each intern meets all requirements and submitting information to the Parent Community Services Branch (PCSB)

·  Once an intern is cleared, he/she is approved to provide services for no longer that a period of one school year

·  The District’s Worker’s Compensation Insurance covers only approved interns

Counselor Signature / Date
Coordinator’s Signature of Approval / Date