Agency Application to Become a Field Site for BSW and MSW Program

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Derek Ryan
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1 Agency Application to Become a Field Site for BSW and MSW Program Revised: 6/2012 Youngstown State University Department of Social Work BSW / MSW Field Education Program One University Plaza Youngstown, OH (phone) (fax) Agency Name: Agency Director or CEO: Address: City, State, Zip: Phone: Fax: Website: Agency Contact for Field Placement: Phone: Please Identify the type of student you are able to educationally accommodate: MSW Foundation (Fall/Spring Semesters), First Year Students MSW Advanced Practice (Fall/Spring Semesters), Second Year Students BSW Students (Two consecutive semesters) The number of students the agency will accept for placement: MSW Foundation Year MSW Advanced Practice Year BSW Students Are you able to accept a student with disabilities? If yes, please comment/describe: 1

2 Stipends: 1. Does your agency provide stipends for students? 2. If yes Number of Stipends Amount per semester Student Orientation: 1. Does your agency provide orientation for students? 2. When is the orientation scheduled? Date(s): 3. Are Student Safety & Risk Management included in Training? Specialized Training Requirements: 1. Does your agency require specialized training or orientation prior to the student s placement? 2. If yes, please describe: 3. How much time is the student required to commit to for this training? Criminal Background Checks/Clearances 1. Does your agency require any of the following? a) FBI Criminal Background Check? b) State of Ohio Criminal Background Check? c) State of Pennsylvania Criminal Background Check? d) Fingerprinting of Students? 2. If yes, who covers the cost of these clearance procedures? a) The STUDENT is responsible for paying for the clearance procedures b) The FACILITY is responsible for paying for the clearance procedures 3. Please identify the cost of these procedures: (if known) a) FBI Criminal Background Check? b) State of Ohio Criminal Background Check? c) State of Pennsylvania Criminal Background Check? d) Fingerprinting of Students? 2

Does your agency require specialized training or orientation prior to the student s placement? 2. If yes, please describe: 3. How much time is the student required to commit to for this training?

3 Medical Clearances: 1. Is the student required to have a physical exam? 2. If yes, a) Can the exam be within one year? b) Can the exam be within 6 months? 3. Who pays for the physical exam? a) The STUDENT is responsible for paying for the physical exam b) The FACILITY is responsible for paying for the physical exam Cost of Exam: (if known) $ 4. What specific medical clearances are required? a) Tuberculosis Test b) Rubella Test c) Measles Test d) Varicella Titer Test e) DPT Test f) Hepatitis B Series g) Other Alcohol & Drug Clearances: 1) Does your agency require a drug test prior to student placement? 2) Does your agency require an alcohol screening test? 3) Is it the agency s policy to require a) random drug testing? b) random alcohol screening? 4) Cost of Drug Testing? (if known) $ 5) Cost of Alcohol Screening? (if known) $ 6) Who pays the cost of the testing? a) The STUDENT is responsible to pay for the testing b) The AGENCY is responsible to pay for the testing Supervision: Please Identify your Educational Degree: (please check those that are applicable) BSW Other Masters Degree: MSW Ph. D. Psychology MSSA Ph. D. Social Work M. Ed Ph. D. Other: Other: Please Identify your level of Licensure, if licensed (please check those that are applicable) LSW PC Psychology 3

What specific medical clearances are required?

4 LISW PCC Other: LISW-S PCC-S Evening & Weekend Placement Opportunity 1. Does the program offer any supervised evening or weekend field hours? Please list the supervised evening & weekend hours a student may be in field: a. Evenings b. Saturday c. Sunday Student Licensure 1. Is the student required to have the LSW Social Work Trainee Status Designation Other Licensure or Certification Describe: Transportation Issues: 1. Is the student required to have a car to carry out his/her internship requirements? 2. Does the agency reimburse the student for agency-related travel expenses? 3. Does the agency s liability insurance cover the MSW student placement? 4. Does the agency require the MSW/BSW student to purchase his/her own liability insurance? 5. Is the student required to transport clients? If yes, a) in the student s car? b) in an agency vehicle Please see Departmental Policy on the transporting of clients Please Identify the best practices utilized by the agency in the assessment/intervention process. (please use the space below box will get bigger with typing) Example: Assessment: Maslow s Hierarchy of Needs Erik Erikson s theory on psychosocial development, ego psychology Life Span Theory Intervention: CBT Narrative Therapy DBT Motivational Interviewing 4

Is the student required to have the LSW Social Work Trainee Status Designation Other Licensure or Certification Describe: Transportation Issues: 1.

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6 If you have more than one placement opportunity for a student, please make a copy of this page and provide a description of the program services, the population served and a student job description for each placement opportunity. Agency Program/Placement Site Information Program Contact for Field Placement: Address: City, State, Zip Phone: (Complete address section if different from main agency) Fax: Briefly Describe Program Service and the Population Served to which the student can be assigned: (attach materials that provide this information) 1. Program Name: 2. Program Name: 3. Program Name: Send above information as an attachment or type information in (box will get bigger with typing) MSW Foundation Year 480 hours (240 field hours each semester) Fall and Spring Semester MSW Advanced Practice Year 540 hours (270 field hours each semester) Fall and Spring Semester BSW Student 450 field hours over two consecutive semesters 225 hours per semester 6

Agency Program/Placement Site Information Program Contact for Field Placement: Address: City, State, Zip Email: Phone: (Complete address section if different from main agency) Fax: Briefly Describe

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8 Agreement and Signature: With the submission of this application to the MSW Field Program,, Name of Agency agrees to be listed on the Online Directory for Field Education and the MSW Program Website. The agency further understands that the information provided in this application is shared with current and incoming field students in order to assist them in becoming more informed about agencies as students seek field placements. Agency Representative Printed Name Agency Representative Signature Date Please send the completed form to: Maureen Reardon, LISW-S MSW Field Education Coordinator Youngstown State University One University Plaza Youngstown, OH fax: or you may also fax or send electronically with signature Theresa Swindler, LISW-S BSW Field Education Coordinator Youngstown State University One University Plaza Youngstown, OH fax:

Field Practicum Liability Insurance Field Form #3

Field Practicum Liability Insurance Field Form #3 Prior to entering your field practicum site, you must apply and successfully receive student field liability insurance through the National Association