Field agency application
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- FIELD AGENCY APPLICATION
- What type of student learner would do best in your agency setting
- Field Instructor Application
- Field Instructors are required to have
- BLANK PAGE WHITNEY M. YOUNG, JR. SCHOOL OF SOCIAL WORK CLARK ATLANTA UNIVERSITY 223 James P. Brawley Dr, SW
- Date: ______________ Name: _____________________________________Home ( )_______________ Name of Agency:_____________________________ Work ( ) ______________
- School (Most Recent First) _________ Degree ______ Date ______Major _______ Social Work License (Kind and Number, if applicable) Date: ____________
- Asian Native American
- Course Title Instructor Given Where Date Areas/Fields of Practice Specialization: Membership in Professional Organizations
- __________________________________________ __________________ Signature Date
- Memorandum of Understanding
- Whitney M. Young Jr., School of Social Work agrees to
- Mutual Responsibilities
- Month/ Day, 2015
- Type Agency Name
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 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 ___Shelter __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 ___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.
------------------------------------------------------------------------------------------------------------------------------------- ____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.
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 BLANK PAGE 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 ____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
email: dwright@cau.edu or fax: 404-880-8556 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 Purpose: 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. General Understanding: 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. Mutual Responsibilities: 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. Signed This ______day of ________. UNIVERSITY NAME of FACILITY & Address Clark Atlanta University Type Agency Name James P. Brawley @Fair Street Type Agency Address Atlanta, Georgia 30314 By: _________________________ By: ____________________ Dr. Darrin E. Wright, LMSW Director Field Instruction & Practicum Activities Whitney M. Young Jr., School of Social Work Date: ____________ Date: _____________ By: __________________________________ Dr. Vimala Pillari Dean Whitney M. Young Jr., School of Social Work Date: ______________ By: ________________________ By: ____________________ Dr. James A. Hefner, Provost and Vice President for Academic Affairs. Date: ______________ Directory: school-of-social-work school-of-social-work -> Whitney m. Young, Jr., Social work field manual/code of ethics acknowledgement form school-of-social-work -> Master of social work program agency Field Supervisor Mid-Semester Evaluation of Foundation Year msw student Practicum Performance Download 97.85 Kb. Share with your friends:
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