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									KU School of Social Welfare▪ Field Education ▪ 1545 Lilac Lane ▪ Lawrence KS 66044 ▪ 785/864-2268 ▪ practicum@ku.edu▪ www.socwel.ku.edu




                                                    AGENCY DATA FORM
                                                     Date Submitted:

Agency Name:                           West Middle/Northwest Middle School
                                       Project Live Program through Friends of Yates Inc

Address:                               2600 N. 44th Street
City/State/Zip:                        Kansas City Kansas 66104
Phone:                                 913-627-6000/627-6018
E-mail:                                rsingleton@friendsofyates.org
                                       rsingl@kckps.org
Agency Website:                        www.friendsofyates.org

Agency Representative to KU: Regina Singleton LMSW
Agency Rep. Contact info: 913-627-6018
Agency Executive: LaDora Lattimore, Executive Director

Attention Agencies: The information contained in this form will be posted on the KUSSW website unless otherwise noted. Check
here is you DO NOT want your agency’s information on our website.

Please indicate the number of students you are able to accommodate in your agency for the academic
year(August-April):

Level of Student(s)       No. of        If                Proposed Field              Field Instructor Email              Check if NEW to
                          Student(s)    Employment        Instructor’s Name &         Address                             KU Field
                                        Based ONLY        Credentials                                                     Instruction (if yes,
                                          (check here)                                                                    please enclose
                                                                                                                          resume)
BSW         (BSW only     1 to 2                          Regina Singleton            rsingleton@friendsofyates.org
available in NE part of                                   LMSW
KS: KC, Lawrence,
Topeka etc)
Foundation: MSW           1 to 2                          Regina Singleton
(1st yr)                                                  LMSW
                                                          Shirley Whitcliff           swhitcliff@friendsofyates.org
Advanced MSW:             1 to 2                          Regina Singleton
Clinical                                                  LMSW
Advanced MSW:
Social Admin.*
Will Take Total           4                               Regina Singleton
No. Students                                              LMSW

          *Agencies requesting Administration students must be able to provide access to agency budgets, personnel policies/ procedures,
          and client outcome data.
Description of Agency Setting and Population Served:
Project Live is a school based intervention program that focuses on working with at risk students and their
families around a variety of issues (anger management, loss and grief, bullying, violence/trauma within the
school, community and home setting, problem solving, making good decisions, living in a domestic violent
situation etc). All of these issues are addressed through group sessions, individual sessions, brief counseling,
KU School of Social Welfare▪ Field Education ▪ 1545 Lilac Lane ▪ Lawrence KS 66044 ▪ 785/864-2268 ▪ practicum@ku.edu▪ www.socwel.ku.edu

crisis intervention with students, some family involvement, education of parents and teachers re: emotional
needs of middle school children.
You will attend IEP meetings, suspension hearings and advocate for students when appropriate to do so.
Friends of Yates incorporated in 1979 as a non-profit organization for the purpose of providing financial strength to the Yates
Branch of the YWCA, when the decision was made by the YWCA to close the Yates Branch the Friends of Yates Inc. in 1982
assumed the sovereignty of Yates and became the governing board. The agency since 1982 as successfully provided
community services of various types to the northeast community of KCK as well as the entire county. Our population focus is
youth, adults and seniors. We have a domestic violence program and shelter for women and their children (Joyce Williams
Center for Battered Women), Project LIVE (middle school community based mental health early intervention and prevention
program serving youth and parents), Emergency food and clothing distribution center, Crime awareness coordinating effort,
Nursing Home Support Group, BRIDGE/SPAN Healthcare Program and summer youth camp program

Learning Opportunities for Students: (educational requirements for practicum for each level of student is
outlined in the attached document entitled “Practicum Planning”).

Students will have an opportunity to work with a culturally diverse population (Hispanic, Asian, African American) in
terms of race, ethnicity, economic, gender, age and traditional and non-traditional family systems. They would have the
opportunity to do individual behavior assessments and plans, groups (loss and grief, anger, ADHD social skills development,
problem solving, to name a few) agency networking and visitation, program development, utilization of assessment tools. This
setting would provide a student with many opportunities to apply theoretical knowledge taught in the classroom setting to the
actual field setting. This is an excellent placement for students wanting exposure working in the areas of child welfare,
school system and mental health system.
PLEASE COMPLETE THIS PAGE – SPECIFIC REQUIREMENTS FOR STUDENT PLACEMENT AT
YOUR AGENCY
Please type (Y=Yes; N=No) to the following requirements that pertain to your agency:
Y        Student needs to mail a copy of his/her resume PRIOR to the interview.
Y     Advanced Level Student needs to bring a copy of his/her foundation-level practicum evaluation (or BSW evaluation if
Advanced Standing student).
N       Professional liability insurance must be obtained by the student, and proof provided to the agency before practicum
begins. (Field Education Office provides information to students on how to obtain insurance)
N        Drug screen required. Does agency pay for this?
N        The student must have a TB check and provide proof to the agency before practicum begins. Does agency pay for
this?        (Note: Field Education Office does not keep student health information)
N        The student must have a physical exam and provide proof to the agency before practicum begins. Does agency pay
for this?         (Field Education Office does not keep student health information)
N        The student must show proof of health insurance coverage.
N        The student must undergo criminal background checks (completed by agency).
Y      The student MUST have their own vehicle to conduct daily agency business: If this is a requirement, are students
reimbursed for mileage?
         If students are required to transport clients, must they have a specified level of automobile liability insurance?
         If YES specify the amount: $
Y Students are expected to share and discuss any current life-issues, (e.g., substance abuse, surviving sexual abuse, chronic
mental illness, etc.) that may affect their ability to work with a specific client population. If this is a requirement, specify
client populations(s): substance abuse
N Students MUST attend certain agency meetings. This is critical information to attempt to avoid potential conflicts with
classroom courses. If this is a requirement please specify the exact day(s) M T W R F and hours:     .
Y        Students are ENCOURAGED to attend certain agency meetings. Please specify the days
KU School of Social Welfare▪ Field Education ▪ 1545 Lilac Lane ▪ Lawrence KS 66044 ▪ 785/864-2268 ▪ practicum@ku.edu▪ www.socwel.ku.edu

M T W R F and hours:             . We cannot guarantee but will make all possible effort to avoid conflicts between meetings
and course schedules. These are not set in stone dates but they will be given advance notice and their schedules will be taken
into consideration so that everyone needs can be best accommodated.
N      A formal, written memorandum of agreement is required by the agency in order to enter into an affiliation with the KU
School of Social Welfare. If required, attach memorandum. NOTE: Please submit no later than the end of May.
Please note any other factors that are important in referring students to your agency for an interview (Anything unusual
      or unique such as agency specific exams, dress code, an early start date or later ending date, required orientation,
      specific student skills such as second language required etc.).

SPECIAL OPPORTUNITIES: Please check any that apply to your agency:

N        We offer student financial assistance. If yes, specify amount and criteria:
N        Agency covers student in case of accidental injury
N        Agency provides students with professional liability insurance for work completed during practicum
Y        We are able to offer a Flexible Time Practicum. If yes, please describe:
Student may be able to start the day later and work a longer day in order to provide the necessary interventions at the school
site in the evening; this would be a one day a week possibility. You can start as early as 7:30 AM but must be at the site by
9:00 AM and end of the day can go until 3:30 or 4:30 PM there are some days that we work a late day such as parent teacher
conferences, school dance in the spring etc.
KU School of Social Welfare▪ Field Education ▪ 1545 Lilac Lane ▪ Lawrence KS 66044 ▪ 785/864-2268 ▪ practicum@ku.edu▪ www.socwel.ku.edu

                                                              Field Instructor Responsibilities
                                                                   Agreement Form
    The Field Instructor is the student's primary educational resource within the agency, and as such agrees to support the educational goals
    of the School of Social Welfare's field education program. The field instructor must be willing to assume the overall responsibility for
    the student's educational experiences in the agency. The time commitment required of a field instructor is approximately 4
    hours/week. To qualify, the field instructor must have a MSW degree from an accredited school of social work and at least two years
    of successful post-MSW experience. If supervising a BSW student, the Field Instructor can have a BSW from an accredited school of
    social work and at least two years of post BSW experience . Specific responsibilities include:
    1.   Prepare for and conduct regularly scheduled weekly conferences with the student. Conferences are 1-1 ½ hours weekly for 30
         weeks. A minimum of 30 hours of field education conferences is expected.
    2.   Collaborate with, and support the student in identifying safety concerns that need to be considered in the agency and practice, and
         develop a safety plan with the student.
    3.   Abide by the NASW Code of Ethics in your relationships with clients, colleagues and students and include discussions about the
         Code of Ethics in the weekly field education conferences with the student.
    4.   Actively collaborate with the student and Field Liaison in the development, implementation and ongoing use of a Learning
         Contract.
    5.   Coordinate any student learning experiences delegated to other staff members.
    6.   Provide the student with ongoing feedback on the student's performance, including evaluation of both process and content oriented
         records that are required by the School.
    7.   Support the student in gaining access to other learning opportunities and resources in the agency and professional community.
    8.   Maintain an ongoing evaluation of the student's progress, and complete written evaluations of the student as required by the School
         of Social Welfare.
    9.   Collaborate with the Field Liaison in planning, review and evaluation of the student's performance and recommend a mid-year and
         final grade to the Field Liaison.
    10. Inform the field liaison promptly of any problem in the field placement and, when necessary, develop a detailed written plan of
        remedial action with the student and field liaison.
    11. Participate in school-sponsored field education meetings, and when new to field instruction in the KU School of Social Welfare,
        attend the seminar for new field instructors in August.
    12. Provide feedback to the field liaison and the Field Education office on the KU Liaison’s performance of their responsibilities.
    13. If not already on file in the Field Education office, complete a resume and submit to the Field Education Office
    For EBP(Employment Based Practicum’s):
    14. Actively collaborate with the student's agency work supervisor to ensure reduction of employment responsibilities, identified
        practicum hours, and appropriate learning experiences very different from the student’s employment responsibilities.
    15. Thoroughly review the students EBP application, showing your agreement and support of KU’s expectations for EBP’s.
    The submission of these materials indicates you have reviewed and agree to provide a practicum setting which meets KU’s learning
    objectives for the level of student you requested, as well as your agreement to abide by the requirements for field instruction. (If the
    field instructor is not the person filling out this form, it is the agencies responsibility to be sure the field instructor receives a copy).

    Regina Singleton LMSW
                                                                     1418 Garfield Ave Kansas City Kansas 66104
    _____________________________________                            Mailing Address

         Signature (not required for electronic submission)          913-321-1566
                                                                     Telephone Number

                                                                     rsingleton@friendsofyates.org
                                                                     E-Mail Address

								
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