University of Pittsburgh



Field Education Directory: Field Placement Availability for

Social Work Students at the University of Pittsburgh

|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/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 V 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 V (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 |

Although the majority of our students will be interning M-F during daylight hours, some of our students may require evening or weekend hours. Please let us know if you are able to 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:

How many students can be accommodated in this agency/site?      

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 attach a description of this agency on a separate sheet. |

| |

|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 placement is 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? (Feel free to |

|attach additional pages as necessary) |

| |

| |

|Agreement and Signature |

|By submitting this survey, I agree to have this agency/organization listed in the Online Directory of Field Education. |

|Name (printed): |

|Date: |

|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.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download