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:
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
Program development/grant writing _____yes _____no
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.):
Are there limits placed on student activities by third party payers, accrediting standards, etc.?
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
___Shelter __Infants and preschool 0-6
___Child Welfare __Children 6-12
___School Social Work __Adolescents 13-18
___School setting __Adults
___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)
___Managed Care __Hispanic-Black
___Community based Mental Health __Caucasian
___Hospital __Caucasian Other (Specify)
___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 Applicationfor 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.
____Agency meet initial best practices criteria for WMYJSSW student(s) placement site.
____Agency does not meet initial best practices criteria for MYJSSW 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
(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
Asian Native American
I will be primary field instructor for ____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.
Please send completed documents to: Clark Atlanta University
Office of Field Education-Thayer Hall 227
223 James P. Brawley Drive, SW
Atlanta, GA 30314
Memorandum of Understanding Memorandum of Understanding between Clark Atlanta University Whitney M. Young, Jr., School of Social Work hereinafter referred to as the “University, and Type Agency Name
The purpose of this Memorandum of Understanding is to guide and direct the parties respecting their affiliation and working relationship to provide high quality professional practices to students in the Clark Atlanta University Whitney M. Young Jr., School of Social Work while at the same time enhancing the resources available to the Facility for providing services to its clients.
Neither party intends for this Memorandum to alter in any way their respective rights or their legal obligations to one another, to the students and faculty assigned to the Facility, or as to any third party.
The University shall provide adequate written information to the Facility regarding the number of students needed prior to the beginning of each semester and submit written schedules including the name of applicable students. The number of students designated for participation in the program will be mutually determined by written agreement of the parties and, may at any time be altered by mutual written agreement. All student participants must be mutually acceptable to both the University and the Facility’s staff and either party may withdraw any student from a program based upon perceived lack of competency on the part of the student, the student’s failure to comply with rules and policies of the Facility or the University, or for any other reason where either party reasonably believes that it is not in the best interest of the program for the student to continue.
There shall be no discrimination on the basis of race, national origin, religion, creed, sex, age, disability or handicap in either the selection of students for participation in the program, or as to any aspect of the professional training; provided however, that with respect to disability or handicap, the disability or handicap must not be such as would, even with reasonable accommodation, in and of itself, preclude the student’s effective participation in the program.
The applicable provisions of Executive Order 11246, Section 503 of the Rehabilitation Act of 1973, and the Vietnam Veteran’s Readjustment Assistance Act, and applicable regulations thereunder are hereby incorporated by reference.
THE TERMS OF THIS MEMORANDUM OF UNDERSTANDING ARE AS FOLLOWS:
Whitney M. Young Jr., School of Social Work agrees to:
Provide assistance in the development of a student learning experience that is in keeping with the School’s objectives for field instruction and compatible with the services offered by the Facility.
Assign a faculty representative as liaison between the Facility and the School of Social Work.
Share with the Facility information about a student’s background, education, personal qualities, interest, maturity, and learning tasks.
Make a minimum of one (1) Facility visit each term a student is in placement and shall make additional visits as needed or on the request of the Facility.
Be on call in emergency situations involving students.
Provide instructional development for Supervisors who request additional techniques, or training in field teaching.
Maintain a professional liability policy for its various professional fields. This program covers all duly registered social work students for events that may occur while performing duties in their field practicum. The policy provides a minimum amount of not less than $1,000,000 per occurrence and no more than an annual aggregate of $3,000,000.
The Facility Agrees to:
Assist in the development of learning experiences for the student(s) in accordance with the professional and educational objectives of Whitney M. Young Jr., School of Social Work.
Accept Student Training as an integral part of the Facility’s operations.
Provide adequate physical space and clerical assistance for the student (s).
Allow Whitney M. Young Jr., School of Social Work faculty liaison opportunities to evaluate student reports and records developed at the Facility
Permit the participation of assigned student field instructors in the following five (5) professional social work education workshops; 1) Orientation to Fieldwork 2) Supervision for Field Supervisors 3) Field Supervisors Teacher 4) Cultural Dynamics of Field Education 5) Ethics for Fieldwork. In addition to, attend periodic University-Facility meetings.
Comply as an equal opportunity Facility.
Personnel of the Facility and the University designated to supervise the student program shall meet at such times as shall be agreed upon by such personnel, which shall be no less than once per year, for the purpose of conducting an ongoing evaluation of the program and participants. The University shall request all participants in the student program to evaluate their experience in the program and shall provide the Facility with full information concerning such evaluation.
Each party (the "Indemnifying Party") agrees to indemnify and hold harmless each other party. (The "Indemnified Party"), as well as the Indemnified Party's officers, directors and employees, together with their successors and assigns from any claim, damage, loss, expense, liability, obligation, action or case of action (including reasonable attorney fees) which the Indemnified party, as well as its officers, directors and employees may or might sustain, pay or suffer, by reason of any act, omission or negligence by the Indemnifying Party. Notwithstanding the foregoing, the Indemnified Party reserves the right to choose legal counsel to represent the Indemnified Party for any purpose including investigation and/or litigation or any claim, or potential claim, made against the Indemnified Party. This section shall survive the termination of this Agreement.
Unless sooner cancelled as provided below, the term of this affiliation for training shall commence on
Month/ Day, 2015 and end on Month/ Day, 2017. This working relationship and affiliation may be renewed by mutual written consent of the parties. It may also be cancelled at any time by either party, with or without cause, upon not less than ninety (90) days written notice. Such notice shall be delivered by hand or certified mail-return receipt requested.