UM SSW Field Placement
New Agency Application
Agency Name »
Agency Old Name
Street Address »
Street Address (line 2)
City » State » Zip »
County »
Phone Number »
(include area code)
Fax Number
(include area code)
Agency Website Address
Name of Administrator »
Intern Coordinator »
Intern Coordinator Phone »
Intern Coordinator E-mail Address »
Agency Mission »
Is this agency licensed/accredited by
any governing authorities? »
Yes No
Please list type of accreditation and year.
Which of the Following Best
Describes Your Setting and Services »
School Clinic
Agency Hospital
In-Home-Service In-Patient-Services
Out-Patient-Services Residential
Community-Based Legislative/Policy
If Other Selected Above, Please Specify
In General, What is the Focus of
the Services Provided »
(check as many as apply)
Aging Adult
Families/Children Low Income
Homeless Behavioral Health
Health Organizational Development
Maternal and Child Health Employee Assistance
Hospice and Bereavement Community Organization
Program Development Advocacy
Social Policy Legislation
What Type Of Organization
is the Agency »
Private Non-Profit
Private For Profit
What are the Days
and Hours of Operation »
Do Social Work Students Serve
Your Agency at a Single or at
Multiple Sites »
Please list intern responsibilities here:»
(Please try to include the following
in your description as this will make it
easier for your interns to become
licensed in the future: "Clinical Social
Work Services", "Perform assessments",
"Diagnosing" and "Providing counseling
or psychotherapy").

What Type of Social Work Activities
Should a Student Expect to
Have if Placed in Your Agency »
(check as many as apply)
Individual Therapy Family Therapy
Group Therapy Discharge Planning
Case Management Community Outreach
Client Education Advocacy
Legslative Activity Community Organization
Program Management
Tasks/Special Projects for this This Year
Please check Yes or No for the following applicable requirements: »
Yes No Criminal Background Check
Yes No Federal Security Clearance
Yes No Child Protective Services Clearance
Yes No Physical Exam
Yes No Motor Vehicle Administration(MVA) Clearance
Yes No CPR/First Aid Certification
Yes No Drug Screening Required
Yes No TB Test Required
Yes No Drivers License Required
Yes No Personal Car Required
Yes No Reimbursement for work related expenses
Yes No Agency Car Provided
Yes No Free Onsite Parking
Yes No
Other Description:
Do You Address the Issue of Personal
Safety in Your Orientation for Students »
Do You Offer a Stipend to Students »
What is the Amount?
Use annual figure; ie. 2200
Has your agency supervised UM SSW students previously? »
Yes No
If yes, when was the first time? (enter year, ie. 2000)
Please Identify Your Preference(s)
for Student Field Placement Days
*Required Select 'No' for all field days if you are not accepting any Foundation or Advanced students. »
Foundation (First Year) Student(s)YesNo
Other, Please Specify or note No Preference
Advanced (Second Year) Student(s)YesNo
Tuesday, Wednesday, Thursday
Other, Please Specify
Do You Accept Extended Students
(advanced students who are in the field 2 days a week from September
through July)
Can You Offer Supervised Field
Instruction on the Weekends
or in the Evenings »
If Yes to Above, Please Describe
How Many Social Workers are
There Within the Agency Who Are Eligible
and Available to be Field Instructors »
Are all of your current field instructors licensed? » Yes No
What is the total number of students you can accommodate from our program each year. »
Foundation (1st Year) »
Advanced (2nd Year) »
How Many From Other Programs »
Other Social Work Programs
(Graduate and Undergraduate)»
Other Non Social Work Programs »
Please Describe Anything Else you Would Like Student to Know About a Field Placement at Your Agency. Please include:
  • Particular Expections
  • Prefences
  • Desired Skills and /or
  • Opportunities
Name of Person Submitting This Form »
Title of Person Submitting This Form »
Phone Number of Person Submitting This Form »
Email of Person Submitting This Form »
<<I have reviewed all the information provided, and to the best of my knowledge the information submitted on this application is accurate.>>