School of Social Work Office of Field Education & Advisement 129 East 79th Street New York, NY 10075
Placement Site Database
Fax: (212) 452-7197
E-mail: mtilden@hunter.cuny.edu
Placement Site: Educational Coordinator: Address: City, State, Zip: Phone: E-mail: Fax: Website:
Complete if different from site information:
Main Agency: Educational Coordinator: Address: City, State, Zip: Phone: E-mail: Fax: Website:
Briefly describe agency mission and population served. Please also give an example of student assignments at your site. (Number and type of cases or groups assigned, examples of community organization or management projects)
WHAT IS THE MAJOR SOCIAL WORK PRACTICE METHOD IN WHICH YOU CAN OFFER STUDENT ASSIGNMENTS? (Check all that apply with ‘X’)
X
MM01 MM02 MM06 MM04
CPIF GW OML
Clinical Practice with Individuals & Families Group Work Organizational Management & Leadership
COPD Community Organization, Planning & Development
2 WHICH OF THE FOLLOWING CATEGORIES BEST DESCRIBES YOUR SITE?
(Check all that apply)
PS 01 PS 02 PS 03 PS 04 PS 05 PS 06 PS 07 PS 08 PS 09 PS 10 PS 11 PS 12 PS 13 PS 14 PS 15
Advocacy/community education program Agency serving the elderly Alternatives to incarceration Ambulatory/primary health care clinic Child welfare agency Child guidance clinic College-based program Community-based organization Continuing day treatment program Corrections/Criminal justice Court setting Early childhood development center Employee assistance program (EAP) Family service agency Hospice
PS 16 PS 17 PS 18 PS 19 PS 20 PS 21 PS 22 PS 23 PS 24 PS 25 PS 26 PS 27 PS 28 PS 29 PS 30
Hospital - inpatient psychiatry Hospital - inpatient medicine Housing/Community development International social work Long term/nursing care facility Out-patient psychiatry clinic Public Welfare Rehabilitation program Residential treatment center School/After-school program Settlement house Shelter/Transitional Housing
Housing Substance abuse treatment program (alcohol/chemical dependency or MICA
Union-sponsored program (MAP) Women’s Center
PROBLEM FOCUS OF PLACEMENT SITE
(Check all that apply)
PROF 01 PROF 02
Academic/behavioral issues -children Alcohol and chemical dependency/substance abuse/MICA At risk-early intervention (ages 0-5) Child abuse and neglect Chronic medical/psychiatric illness Death and dying Developmental disability Disability Domestic violence Education/special education Elder abuse Family relationships Foster care Frail/homebound elderly Gender identity/coming out
PROF 16 PROF 17
HIV/AIDS Homelessness Immigration/Refugee issues Incarceration Medical illness Parole/probation Preventive services/permanency planning Psychiatric illness Social justice Unemployment/Employment Victims of crime or violence Welfare rights Well elderly Wellness/prevention Women’s rights/issues
PROF 03 PROF 04 PROF 05 PROF 06 PROF 07 PROF 08 PROF 09 PROF 10 PROF 11 PROF 12 PROF 13 PROF 14 PROF 15
PROF 18 PROF 19 PROF 20 PROF 21 PROF 22 PROF 23 PROF 24 PROF 25 PROF 26 PROF 27 PROF 28 PROF 29 PROF 30
3 PRACTICE FOCUS OF PLACEMENT SITE (Check all that apply)
PRAF 01 PRAF 02 PRAF 03 PRAF 04 PRAF 05 PRAF 06 PRAF 07 PRAF 08 PRAF 09 PRAF 10
Individual casework Family counseling Case management Crisis intervention Group (educational) Group (supportive, therapeutic) Group (activity) Play therapy Grant writing Supervision POPULATION GROUPS SERVED AT YOUR SITE (Check all that apply)
PRAF 11 PRAF 12 PRAF 13 PRAF 14 PRAF 15 PRAF 16 PRAF 17 PRAF 18 PRAF 19 PRAF 20
Legislative advocacy Grassroots organizing Policy analysis Staff development/training
CommunityEducation/Leadership Development
Program Planning /Evaluation Community Building Spirituality and Healing Rehabilitation Dance/Drama/Art Therapy ADDITIONAL LEARNING EXPERIENCES AVAILABLE TO STUDENTS AT YOUR SITE (Check all that apply)
PG 01 PG 02 PG 03 PG 04 PG 05 PG 06 PG 07 PG 08 PG 09 PG 10
Children Adolescents Adults Older Adults Intergenerational Individuals Families Groups Communities Organizations AGENCY AUSPICE (Check all that apply)
LE 01 LE 02 LE 03 LE 04 LE 05 LE 06 LE 07
In-service training Student seminars Staff Meetings Case conference Grand rounds Inter-disciplinary teams/collaboration Practice-based Research
CLIENTS SERVED AT YOUR SITE (Check all that apply)
A 01 A 02 A 03
AA 01 AA 02 AA 03 AA 04 AA 05
Public (City) Public (State) Public (Federal) Not-for-Profit/Voluntary For Profit/Proprietary
Voluntary Clients only Mandated Clients only Both Voluntary and Mandated Clients
Please answer the following questions:
Q01 Q02 Q03 Q04 Q05 Q06
4
Number of First Year students you can accommodate? Number of Second Year students you can accommodate? Number of OYR (Work Study) students you can sponsor? Does your agency have a SIFI-certified Field Instructor(s)? Does your agency have a SIFI-eligible MSW? *See FI Requirements below If students are expected to make home visits, do you provide (a) Escorts (b)Transportation
YES YES YES YES NO NO NO NO YES YES
___(#) ___(#)
NO NO
Q07
Does your agency provide reimbursement for transportation to and from agency assignments? Is your agency accessible by subway? If yes, nearest subway lines:
Q08
Q09
Is your agency accessible by bus? If yes, nearest bus lines:
YES
NO
Q10 Q11
Does your agency provide stipends for students? If yes, (a) Number of stipends (b) Amount
YES
NO
Q12
Does your agency provide an orientation for students? If yes, when is it held?
YES
NO
Q13
Can your agency provide adequate space and resources for an intern (i.e., desk, phone, computer access [for required documentation], private space to meet with clients, etc.)? Does your agency require a formal affiliation agreement with the School? If so, provide the name of a contact person: Does your agency have an established and communicated sexual harassment prevention policy and procedure?
YES
NO
Q14
YES
NO
Q15 Q16
YES
NO
*Field Instructor (FI) Requirements: MSW degree from an accredited school of social work 3 years of post-MSW agency practice experience NYS license (or another state’s equivalent) and current registration either as a licensed master social worker (LMSW) or a licensed clinical social worker (LCSW) –unless exempt by virtue of employment until January 2010.
5
If your agency requires physical examination or other tests for students, please provide the following information (please check):
REQ 01
Does your agency require students to have a physical examination prior to placement? If yes, how recently must the student have had this physical exam? (a) Within one year (b) Within six months
YES
NO
REQ 02
REQ 03
If yes, does your agency provide the resources for a physical exam for students? Does your agency expect students to provide evidence of having had the following medical tests? (a) Tuberculosis (b) Rubella (c) Measles (d) Varicella Titer (e) DPT
YES
NO
REQ 04
REQ 05 REQ 06
Does your agency provide the resources for these tests? Does your agency expect students to show proof of these tests prior to the start of the practicum? Who should students contact in the agency for further information about these examinations or tests? Name: Phone #: Other requirements:
YES YES
NO NO
REQ 07
REQ 08 REQ 09 REQ 10 REQ 11
Does your agency require a background check? Does your agency require a drug screen? Does your agency require fingerprinting of students? If yes, does your agency pay for these tests? Specify which test(s) the agency pays for:
YES YES YES YES
NO NO NO NO
Agency representative completing this form: Date:
Rev. 5/2009