University of Pittsburgh

							                               Field Education Directory: Field Placement Availability for
                                  Social Work Students at the University of Pittsburgh
                        (press <tab> to move from one section to the next AND click on the checkboxes with the mouse)
AGENCY DEMOGRAPHIC INFORMATION                                                                                 Direct Practice        COSA
Agency Name


Program / Site / Department Name (if different than Agency Name)


Agency / Site Address


City                                           State       Zip                        County                Telephone:


Agency / Site Website Address / URL:                                                                        Fax:


Agency / Site Contact                                                                                       Telephone:


Agency / Site Contact E-Mail                                                                                Fax:


AGENCY/SITE REQUIREMENTS                    Requires a cell phone for field communication
Transportation:       Is on a bus line      Requires a car for work-related travel        Reimburses program-related travel expenses
Screenings:           Medical               Drug     Clearances:            Act 33        Act 34       FBI Fingerprinting/Other:
Trainings Provided:        Safety Training        HIPAA Training            Agency Sponsored
AGENCY/SITE STIPEND INFORMATION
Does the Program offer a Stipend?        Stipend Amount:      Stipend Description:  Other:
   Yes        No                         $                        Weekly            Semester           Lump Sum
CSWE CATEGORY - Choose one category that best describes this site. Required by Council of Social Work Education for accreditation
       Administration                     Community Planning                      Family Services      International             Race/Social Problems
       Aging / Gerontology                Corrections/ Criminal Justice           Group Services       Mental Health             Rehabilitation
       Alcohol/Drug/Substance Abuse       Developmental Disabilities              Health               Occupational              School Social Work
       Child Welfare                      Domestic Violence/Crisis Intervention   Housing Services     Program Evaluation        Social Policy
                                                                                                       Public Assistance         Other:
AGENCY/SITE SETTING - Choose no more than three (3) settings that best describe this program
       Administrative Unit                      Educational Unit                  Inpatient Unit                         Rural
       Advocacy                                 Elder Care                        Interdisciplinary                      School-Based Mental Health
       Business                                 Emergency / Crisis Center         Multicultural Organization             After-School Program
       Community-based Health Care              Employee / Student Assistance     Nursing Home                           School Social Work
       Community-based Social Service           Faith-based Organization          Outpatient Mental Health - Adult       Substance Abuse
       Community-based Mental Health            Family Service                    Outpatient Mental Health - Child       Urban
       Community-based Organization             Government                        Psychiatric Hospital                   Volunteer-Based Program
       Community Center                         Health Care                       Rehabilitation Program                 Other:
       Correctional                             Homeless                          Residential Correctional
       Court / Justice System                   Hospice                           Residential Treatment – Adult
       Day Treatment Program                    Hospital                          Residential Treatment – Child
       Domestic Violence                        Inpatient Mental Health           Respite Care
AGENCY/SITE CHARACTERISTICS - Choose characteristics that best describe field work activities in this program
       Abuse & Neglect                          DSM IV Disorders                  Juvenile Delinquency                   Protective Services
       Adoption                                 Eating Disorders                  Legal Issues / Systems                 Public Welfare
       Adventure Education                      Elderly                           Legislative Issues                     Reproductive Issues
       Advocacy                                 Emotionally Disturbed             Maternal & Child Health                School Social Work
       AIDS & HIV                               Family Systems Treatment          Mental Health / Illness                Sexual Abuse & Assault
       Alzheimer’s / Dementia                   Foster Care                       Oppression & Injustice                 Special Education
       Child Welfare                            Gay / Lesbian / LGBT Issues       Parenting                              Social Justice
       Community Development                    Health Care                       Parole / Probation                     Substance Abuse
       Crisis Intervention                      Homelessness / Housing            Pervasive Development Disorders        Suicide Prevention
       Death & Dying                            Infant Mental Health              Physical Disabilities                  TITLE IV E
       Developmental Disabilities               Immigration/Refugee Issues        Poverty
       Domestic Violence                        Job Preparation & Development     Pregnant Teens/Parenting
PRACTICE SKILL AREA - Choose the major skill sets gained through the field work activities in this program
    Advocacy                                          Data Collection                                Individual Treatment                          Research and Analysis
    Assessment & Evaluation                           Discharge Planning                             Legislative Advocacy                          Service Provision
    Behavior Modification                             DSM IV (Diagnostic work)                       Mediation                                     Team Building/Coalition
    Board Development/Governance                      EAP counseling                                 Needs Assessment                              Volunteer / HR recruitment
    Budgeting                                         Foundation Work                                Planning/Program Evaluation                   Other:
    Case Management                                   Fundraising                                    Policy Analysis & Development
    Committees / Task Force                           Grant Writing                                  Prevention
    Community Development                             Grassroots organizing                          Program Administration
    Community Outreach                                Group / Family Treatment                       Program Development
    Couples Treatment                                 Information and Referral                       Public relations/marketing
    Crisis Intervention                               In-home Intervention                           Report Writing/Recording


Can you offer 12-24 hours per week of supervised field placement during evenings and/or
weekends?             Evenings     Weekends      Both Evenings & Weekends
Please review student competencies and on-line descriptions of learning expectations for
BASW or MSW students before completing the section below. Available for review at:
http://www.socialwork.pitt.edu/academic-programs/field-education/
    How many students can be accommodated in this program?
    Of the students that can be accommodated, will your agency accept?
                         BASW Students
                         First Year MSW Students
                         Advanced Standing and Second Year MSW Students
                         Both First and Second Year MSW Students

AGENCY / SITE DESCRIPTION - Please (1) attach a description of this agency as a separate file or (2) type the agency information
below. (This section will expand as you type.)

  Agency Description Information is requested so that we can include this on the Field Education website. Students use this
  information more than any other source to determine their placement preferences. Please use this as an opportunity to
  focus on any unique features of your agency. Additionally, please outline what learning opportunities are available at the
  field site for students to achieve program competencies.




AGENCY/SITE FIELD INSTRUCTORS

  Each Field Instructor, who will supervise the students in this (these) placements, are required to complete a Field
  Instructor Application and attach a resume / CV.

Are there additional opportunities for field placements within your agency/organization? If so, what are they and where are they
located? (this section will expand as you type)


Agreement and Signature
By submitting this survey, I agree to have this agency/organization listed in the Online Directory of Field Placement.
Name (printed):
Date:
Please email this completed form to University of Pittsburgh Field Education Office: sswfield@pitt.edu
Our Policy
It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual orientation, age, or disability
FOR SSW FIELD EDUCATION STAFF USE ONLY
ASSIGNED AGENCY & PROGRAM #                                            DATA ENTRY DATE                         DIRECTOR APPROVAL
                       This form was created in consultation with the North Central Field Education Consortium.