University of Pittsburgh s2

Field Education Directory: Field Placement Availability for Social Work Students at the University of Pittsburgh (press to move from one section to the next AND click on the checkboxes with the mouse) 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 Fingerprinting/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 IV 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 IV (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

Can you 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: http://www.socialwork.pitt.edu/academic-programs/field-education/ How many students can be accommodated in this program? 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 (1) attach a description of this agency as a separate file or (2) type the agency information below. (This section will expand as you type.) 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 (these) placements, are 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? (this section will expand as you type)

Agreement and Signature By submitting this survey, I agree to have this agency/organization listed in the Online Directory of Field Placement. Name (printed): Date: Please email this completed form to University of Pittsburgh Field Education Office: [email protected] 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.