Field agency application



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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.





Criteria for Field Instructors



Field instructors are expected to have at least one degree in social work and have a demonstrated interest in serving in a teaching role with students. Agency staff desiring to serve in this capacity is selected following a review of their interest, training, experience, academic preparation, and ability to provide appropriate supervision for students.

Clark Atlanta University Whitney M. Young, Jr. School of Social Work Program adheres to the following interpretative guidelines of the Accreditation Commission of the Council on Social Work Education in regard to the criteria for selecting field instructors:

Assessment of a field instructor’s qualifications should take into account the individual’s professional education, commitment to the values of the social work profession, competence in practice, and interest in supporting student education. A basic requirement for assuming field instruction responsibilities is the agency’s adjustment of the individual staff member’s work assignments to permit adequate time to develop and implement the student’s field practicum. The field practicum plan should give the student regular access to the field instructor.




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



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