Field agency application
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- WMYJSSW Office of Field Instruction Field Agency Application, page 2 What type of student learner would do best in your agency setting
- Field Instructors are required to have
- WHITNEY M. YOUNG, JR. SCHOOL OF SOCIAL WORK CLARK ATLANTA UNIVERSITY 223 James P. Brawley Dr, SW Thayer Hall-rm 227
- Please fill in this sheet carefully, as it will be used in compiling data for our school bulletin and for Field Education records. Please attach a resume to this
- Name of Agency:_____________________________ Work ( ) ______________ Address: E-mail: _____________________________________________________
- Social Work License (Kind and Number, if applicable) Date: ____________ Professional Experience Agency Dates Position Full or Part-Time
- I will be primary field instructor for an ____MSW student _____BSW student for the first time*
- Other Supervisory Experience (Social Work): Agency Dates Supervisees Educational Level Courses in Supervision Completed
- I have read the criteria for Agency Field Supervisors, and I agree to abide by and represent these standards. I agree to act as the student’s Agency Field Supervisor for the full academic year.
| Whitney M. Young Jr., School of Social Work
Thayer Hall-room #227 Clark Atlanta University 223 James P. Brawley Drive, SW Atlanta, GA 30314 FIELD AGENCY APPLICATION THE INFORMATION REQUESTED is for the purpose of helping you and the office of Field Education and Practicum Activities decide whether your participation in the undergraduate/graduate field practicum program would be mutually beneficial. The data provided below and in discussion with the WMYJSSW Director of Field Education and Practicum Activities are appreciated. Agency Name: Address: Phone: Fax: Administrator: Director of Social Services (if different from above): Briefly describe the Agency’s principal function(s): In which state, regional, and national organizations does the Agency have membership? How many students would you be willing to have from WMYJSSW at the same time? (WMYJSSW social work students are typically placed in the same agency for 2 semesters, Fall and Spring): BSW Level student(s): _____ 1st year student(s): _____ 2nd year student(s): ______ Can the Agency provide interviewing space, telephone service, clerical support and other necessary requisites to student functioning? Does the Agency have In-Service Education Programs, consultation or other staff development activities in which the student would participate? (Please briefly identify these) How much time per week could the recommended Agency Field Supervisor provide for reviewing student records, and for conferring with students and WMYJSSW Faculty Field Liaisons? Does the Agency work with other community facilities? _____Yes ____No (If yes, briefly indicate nature of collaboration) Indicate the types of clients with whom students would work: Which treatment or service modalities does the Agency offer? Which services would students be expected to provide? Are there opportunities for the students to engage in: Individual case work, counseling, or treatment _____yes _____no Work with families _____yes _____no Work with communities _____yes _____no Group Work _____yes _____no Research/evaluation opportunities _____yes _____no Planning/ administration _____ yes ____ no Social action/policy advocacy _____ yes_____no Program development/grant writing _____yes _____no WMYJSSW Office of Field Instruction Field Agency Application, page 2 What type of student learner would do best in your agency setting? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Are students covered by an agency automobile liability insurance policy? No Yes (If so, please attach a copy of the policy) Are students covered by an agency professional liability insurance policy? ______ No _____ Yes (If so, please attach insurance policy Please indicate “Yes” or “No” on the following which are required of internship students: A car needed to reach your site? _______ Car needed to complete practicum activities and services to client population Valid State of Georgia driver’s license Special insurance coverages (auto, health, etc.): Please specify: Special health screening or medical tests (TB, physical examination, etc.): Please specify: Background check Drug/alcohol screening Are there limits placed on student activities by third party payers, accrediting standards, etc.? No Yes (please describe): Do you provide stipends to students? ____yes ____No If so, how much per semester?_____________ Does your agency provide/reimburse students gas/mileage incurred while performing activities on behalf of your agency? ____yes _____No Do you have late evenings and weekend placement opportunities? ___yes ____No Please complete the following information about your agency (check all that apply) Type of setting Population Served ___ Skilled care __Elderly __Infants and preschool 0-6 ___Child Welfare __Children 6-12 ___School Social Work __Adolescents 13-18 ___School setting __Adults ___Coalitions __Families ___Community Organizing __Gay& Lesbian ___Developmental Disabilities __Women ___Community based family services __Men ___Forensic /corrections __Newcomers& Refugees ___Foundations __African Americans ___Health/Public Health __Black Other (Specify) ___Housing __Hispanic-White ___Managed Care __Hispanic-Black ___Legislative/Government __Asian ___Community based Mental Health __Caucasian ___Hospital __Caucasian Other (Specify) ___Hospice ___Shelter ___Other (specify) Please provide any other information you believe to be relevant in providing a social work field education placement. Date application completed: By: In addition to this application, please complete and submit a Field Instructor Application for all persons who wish to act as a Field Instructor with WMYJSSW Social Work Interns. Please also attach a current resume for each individual applying. Thank you, Please do note write below; School use only. ------------------------------------------------------------------------------------------------------------------------------------- ____Agency meet initial best practices criteria for WMYJSSW student(s) placement site. ____Agency does not meet initial best practices criteria for WMYJSSW student(s) placement site.
Field Instructors are required to have: a Master’s degree from an accredited school of social work a minimum of two years postgraduate work experience in the area in which s/he is supervising a minimum of one year work experience on staff available to conduct field instruction meetings with the students weekly (i.e. one hour individual instruction per student per week) an ongoing commitment to professional social work education knowledge of the agency, its policies, procedures and its relation to the community willingness to participate in training and other field events, and to work with the Schools' liaison throughout the field education process an understanding of adult learning styles the ability to provide structured learning experiences experience and knowledge of the aging process WHITNEY M. YOUNG, JR. SCHOOL OF SOCIAL WORK CLARK ATLANTA UNIVERSITY 223 James P. Brawley Dr, SW Thayer Hall-rm 227 Atlanta, GA 30314 AGENCY FIELD SUPERVISOR PROFILE (To be filled out by all agency field supervisors – Please print or type) Please fill in this sheet carefully, as it will be used in compiling data for our school bulletin and for Field Education records. Please attach a resume to this profile. (Field Supervisor must have 2 years post MSW work experience) Date: ______________ Name: _____________________________________Home #( )_______________ Name of Agency:_____________________________ Work #( ) ______________ Address: E-mail: _____________________________________________________ Position in Agency: ___________________________________________________ Education: School (Most Recent First) _________ Degree ______ Date ______Major _______ Social Work License (Kind and Number, if applicable) Date: ____________ Professional Experience Agency Dates Position Full or Part-Time Ethnicity African-American/Black Hispanic/Latino Asian Native American Other Caucasian I will be primary field instructor for an ____MSW student _____BSW student for the first time* YES___ NO___ *If YES, all new field instructors are required to take our field supervisor seminar which is given in the Fall. *If NO, please write prior field instructor experience of MSW and/or BSW students School of Social Work Field Agency Year # Supervisees Other Supervisory Experience (Social Work): Agency Dates # Supervisees Educational Level Courses in Supervision Completed: Course Title Instructor Given Where Date Areas/Fields of Practice Specialization: Membership in Professional Organizations: I have read the criteria for Agency Field Supervisors, and I agree to abide by and represent these standards. I agree to act as the student’s Agency Field Supervisor for the full academic year. __________________________________________ __________________ Signature Date Please send completed documents to: Clark Atlanta University Office of Field Education-Thayer Hall 227 223 James P. Brawley Drive, SW Atlanta, GA 30314 Or By fax @ 404-880-8556 WMYJSSW Office of Field Instruction: Agency Profile Application Page Directory: CMFiles -> Docs Docs -> Cau athletics Participates in Health Awareness Initiative atlanta, Ga Docs -> Contact: Larry Calhoun 404-880-6040 Docs -> C do not write in this area. 2 0 1 0 0 / lark Atlanta University irb application Cover Sheet Docs -> Spring 2009 semester Docs -> History Whitney M. Young, Jr., School of Social Work 0 Download 59.72 Kb. Share with your friends:
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