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									                                 Application for Work/Study Field Placement

                                          Please submit this form in duplicate!
This application is for students who are interested in using their current job in Social Work as their field instruction
site. To be considered for a work/study:
     1) The student must have been employed by the agency for at least six (6) months;
     2) The agency must be willing to reassign the student for the hours of the placement to a different job (this could be a
different unit, different population, different tasks within same unit); and
     3) The agency must be willing to assign a different supervisor to supervise the student’s educational job experience.
The supervisor must be a licensed MSW-level social worker, have at least 3 years post-MSW experience, and have
completed or be willing to complete simultaneously the Seminar in Field Instruction (SIFI).

Work/Study applications for the Fall must be submitted before June 30th. All applications will be reviewed and the
director of the agency will be contacted for verification of the work/study plan. The Field Instruction Department
reserves the right to determine if your request is educationally sound.

Name (Please Print) _____________________________ Social Security Number:
Agency Name:                                                             Agency Phone:
           Department where you currently work(if applicable)
           Address where you currently work:
           City, State, Zip ______________________________ Start Date of Employment _____________
Agency Director 1                                                        Director’s Phone:
Have you discussed this work/study plan with your Director: Yes                        No
(If not, please do so. The Director is required to sign the attached sheet for approval, and will receive the Agreement from the school)

Name of Current Work Supervisor: ______________________________________
Student’s Concentration:
Foundation (1st year)        Advanced Year Clinical       Administration       Client Centered Mgt                                  Research
Where will you be attending Integrative Seminar: Lincoln Center       Tarrytown
If your Employment is being planned by NYC ACS, you do not need to submit this application. You do need to have indicated on
your field planning form that you are an ACS employee who will be placed by ACS.
Will the Field Instructor and/or student both be at the above address:                   Yes           No
         IF NO, where will the student be for field placement ? (If the student will be at the above current work address, leave
Site Name:                                                               Site Phone:
           Department (if applicable)
           City, State, Zip
         Where will the Field Instructor be? (if not at agency address above or if in a different location from the student)
Site Name:                                                               Site Phone:
           Department (if applicable)
           City, State, Zip

  Please list the Educational Coordinator of the agency’s field work program if one exists. If there is no educational
coordinator, list the Director of the Agency or the person who would have final approval of the planned arrangement.
                                            Work Study Proposal
This Field Work Proposal should be developed jointly and signed by the student and the agency person
responsible for coordinating field placements.

A. Describe the student’s current regular work assignment and duties.

B. The practice component of the approved placement hours must be new work. Explain specifically how the
   student’s practice assignments will be different from the current work assignment. (Attach an additional
   page if necessary).
        Difference can include, but is not limited to:
        1. Placement in a different unit of the agency
        2. Different clients and different type of clients (explain how they are different)
        3. Different mode of intervention, e.g., leading groups, working with families, administration for a
           student who currently works in direct service, some long term cases (if not part of the current
        4. Other new activities, such as developing a new or innovative service.

How many hours will the student be doing field instruction weekly? 14 hrs          21 hrs        28 hrs
C.      Proposed newly assigned field instructor:
     1. Name:                                                     Phone #:
     2. Post MSW practice experience (3 years minimum):                   years
     3. State Where Social Work License Issued: _______ License #: _____________ Exp. Date: _________
     4. Has taken the “Seminar In Field Instruction” Yes           No        [If No, you will be required to take it
        while providing field instruction to the student.]

        If “yes”, where and when did you take it?
        SIFI completed at (School)                                                Year
     5. Will be able to provide 1.5 hours a week of supervision: Yes          No

                Student Signature                         Agency Representative Signature
Date Signed: __________________________

                                                                 Telephone #
To whom (agency personnel) and to what address should we mail back the approved, signed agreement:
                           For Field Instruction Department Use Only

Are new assignments sufficient for the placement hours requested: Yes       No

If NO, what hour plan is being approved: 14      21
(Reduced Field Work Students’ Plan must incorporate 28 hours)
Note: 21 hour placements will have 12 hours per week of different/new clients or practice assignments. 14 hour
placements will have 8 hours of different/new clients or practice assignments. Reduced field work students (28
hours) will have 16 hours of different/new clients. The remainder of the placement hours will be for
administrative paperwork, supervision, meetings, case conferences, trainings/learning experiences, etc.

Modifications to the proposal agreed to in conference prior to acceptance:

Modifications discussed with ________________________ at agency.

Proposal Accepted as Submitted:                 Proposal Accepted as Modified:
Proposal Rejected:         Reason(s):

                      Coordinator                                             Date

Placements approved will be for the full academic year. Students are not guaranteed approval for changes due to
alteration in their employment status.

Changes (if necessary) forwarded to Field Placement Site on (date): _____________________

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