#20 AURORA UNIVERSITY SCHOOL OF SOCIAL WORK BSW FIELD APPLICATION: 2016-2017 INSTRUCTIONS: This form is to be completed by the student when there is an agreement with an agency about initiation of a field placement. Submit form via mail or email to:
Dan Knapp Ph.D. Date of Application: ______Director of Field Instruction 347 South Gladstone Avenue ** Note, failing to answer any question will Aurora, IL 60506 result in an incomplete application [email protected]
NOTE: YOU CANNOT BEGIN THIS INTERNSHIP UNTIL THIS FORM IS COMPLETED BY STUDENT, APPROVED BY THE DIRECTOR OF FIELD INSTRUCTION, AND YOU RECEIVE A CONFIRMATION LETTER.
Student ______Last First Phone (H/C) (W)
Address ______Street City State Zip
AU email ______
Select your preference of times for your Field Seminar class for the 2016-2017 academic year. The field office will place you in your Field Seminar class based on a variety of factors including your preference below. Tuesdays 12-12:50 Tuesdays 5:30-6:20 Thursdays 12-12:50 Thursdays 5:30-6:20
FIELD AGENCY INFORMATION
( ) AGENCY/SCHOOL DISTRICT # AGENCY PHONE
STREET CITY STATE ZIP (MUST BE A STREET ADDRESS NOT A PO BOX)
Agency Field Instructor (MSW) ______Phone: (___)______***Primary MSW supervisor*** Field Instructor Email: ______
Is my proposed field supervisor an MSW with two years of post-graduate experience? YES NO If the answer is NO, refer to the Field Manual and contact the field office for additional guidance.
Other personnel involved with field instruction on site: Name: ______Phone: ______
1 ______Student Name Will placement begin early (before the semester begins)? ____Yes ____ No
PLACEMENT BEGINS ______ENDS ______(please indicate semester/year)
Is this field placement your place of employment? ____Yes ____ No (if Yes- an additional JAI form is needed before placement is approved)
Are you seeking this placement to count towards a specialization? If so, CIRCLE which one. CHILD WELFARE ADDICTIONS FAITH-BASED
Internship Tasks will involve: (Choose all that apply) __ Administration/Planning __Advocacy __Child Welfare
__Criminal Justice/Corrections __Disabilities __Family Services
__Gay/Lesbian Population __Gerontology/Aging __Health/Medical __HIV/AID Population __Homeless Population __Hospice/Bereavement
__ International/Global __ Occupational/ Industrial __Mental Health
__ Public Welfare/Assistance __School Social Work
__Substance Abuse/Addictions __Women’s Issues/Family Violence/Sexual Assault
__Other (please specify) ______
Previous Experience Please attach a resume to this application. Reviewing your experience in the field of social work is essential to ensure your field placement will provide new social work learning experiences.
How many years of previous, paid social work or social service experience? ______years
Have you worked within a social service organization serving a similar population as the placement you plan to complete this academic year? ____Yes _____No
List areas of social work in which you have worked: ______
Schedule Commitment for Field Placement Below please provide your plan for participating in your field placement. The plan should encompass your ability to secure 225 field hours each semester (on average 15 field hours weekly).
Mon: ______Thurs: ______
Tues: ______Fri: ______
Wed: ______Sat: ______Sun: ______
______Total weekly Field Hours ______Schedule To Be Determined 2 ____ My Field Instructor has agreed to my planned schedule. ______Student Name
SPECIAL ISSUES OR CONCERNS- REQUIRED Have you (student) ever been convicted of a felony? If so, please explain:
Have you (student) ever been convicted of a misdemeanor involving domestic violence or the maltreatment of a child or an elderly person? If so, please explain:
List any languages (other than English) that you (student) speak fluently:
Does this placement involve any conflict of interest for the student or supervisor? (e.g. have you worked here, student received services as client of agency/supervisor, student’s family member employed at agency/school):
Are there any special skills that you (student) can offer to your field experience? If so please list.
If you have any issues or concerns that may have a direct impact on your field placement, please contact the Director of Field Instruction immediately 630-947-8936. These issues include but are not limited to issues such as substance abuse recovery and mental health concerns. Providing this information will assist the Director of Field Instructor in assisting you in finding a placement that you find comfortable. Information provided will be treated confidentially.
Field Interview Specifics
Please discuss EACH of these questions below during your interview. Mark ‘yes’ or ‘no’ for each question.
_____ Weekly- 1 hour individual supervision will be provided by MSW at placement.
____Must you have a criminal background check? ______Who is responsible for securing this check?
_____ Must you provide medical information? ______Must you provide proof of auto liability insurance?
______Will you be responsible for transporting clients? ______Must you have specialized training?
______Who is responsible for providing? _____ Is there a cost? ______Who will pay?
______Is training provided for personal safety issues, such as home visits, dealing with hostile clients, etc.?
3 ____ Expectations about dress code were reviewed. ____ required paperwork reviewed.
______Student Name
Please Indicate (by placing an ‘x’) the overall Type of Placement. Select no more than 2 1_____ Addictions 2_____ Administration 3_____ Advocacy 4_____ Aging/Gerontology Social Work 5_____ Child welfare 6_____ Community Development 7_____ Community Mental Health 8_____ Corrections/Criminal Justice 9_____ Developmental Disabilities 10_____ Displaced persons / homeless 11_____ Domestic violence / violence 12_____ Family Services 13_____ Global / International Social Work 14_____ Health / Integrative Health or Mental Health 15_____ Immigrant / Refugee Work 16_____LGBTQ 17_____ Military Social Work 18_____ Occupational or rehabilitation Social Work 19_____ PTSD / Veterans 20_____ Program Evaluation 21_____ Public Assistance / Public Welfare 22_____ School Social Work 23_____ Social Policy 24_____ Other: ______
Minimum Responsibilities of the Agency Field Instructor (MSW or task supervisor at the agency/hospital/school designated as party responsible for training the social work student in the field):
1. Provide a minimum of one hour of supervision each week, providing guidance, training, processing, assignment and evaluation of social work field student.
2. MUST Provide learning activities that allow the student to develop skills in 10 competency areas as defined by CSWE EPAS 2008. Students must have learning activities in each competency area. ______2.1.1 Identify as a professional social worker and conduct oneself accordingly. ______2.1.2 Apply social work ethical principles to guide professional practice ______2.1.3 Apply critical thinking to inform and communicate professional judgments ______2.1.4 Engage diversity and difference in practice ______2.1.5 Advance human rights and social and economic justice ______2.1.6 Engage in research-informed practice and practice-informed research ______2.1.7 Apply knowledge of human behavior and the social environment ______2.1.8 Engage in policy practice to advance social and economic well-being and to deliver effective social work services ______2.1.9 Respond to contexts that shape practice ______2.1.10 Engage, assess, intervene, and evaluate with individuals, families, groups, organizations and communities
3. Assist student in completing required field assignments (learning agreement, semester evaluations).
4. Assist student and field liaison in scheduling and facilitating field liaison visit (minimum of 1 visit each placement). Utilize field liaison for problem solving should the need arise.
4 MINIMUM STUDENT RESPONSIBILITIES Please read carefully and indicate awareness of responsibilities with your signature and date.
* I understand that the Field Manual is the “textbook” for my field placement. I also understand it is my responsibility to download and be familiar with this manual. This manual is located on Aurora University website. Additional forms and instructions will be indicated on Moodle page for this course.
* I understand that my field placement is for two consecutive semesters (unless otherwise arranged; PEL: Social Work; Summer Block; Early Start). If there are issues that arise which will effect my continued placement I will contact my Field Liaison or the Director of Field Instruction immediately .
* I understand that I must complete a minimum of 225 for Foundation or 250 for Addictions field hours at the end of every semester in order to receive credit for each Field course. I also understand that failure to submit my semester evaluations can result in receiving no credit for my field experience and prolong my academic involvement in school.
* If I am a MSW student and my placement is in a school social work setting, the placement will end in late May or early June per the terms of the contract I have signed with the school district. I understand that I will participate in the Aurora University graduation ceremony in May, but my actual graduation date will be in the summer of that year.
* I understand that I must treat my field placement in a professional manner which will include, notification of absences or being late to my field instructor or agency/school supervisor, dressing in an appropriate manner for my placement, being knowledgeable about agency/school policies, etc.
* I understand that the field experience continues until I’ve reached the mutually agreed upon end date and goals for completion that were created with my field supervisor and the host agency, and this could result is me accruing more hours than the required minimum amount.
* I understand my responsibilities in cooperating with my assigned Field Liaison; this includes phone contacts and attending meetings.
* I understand that I am not permitted to terminate the field placement; I need to notify my Field Liaison or the Director of Field Instruction.
* I understand I may not begin my Field Placement hours until I receive a confirmation letter from the Director of Field Instruction.
* I verify that I have read the Aurora University School of Social Work Field Instruction Manual. I fully understand the policies, procedures, and guidelines included.
______Student Signature Date
______MSW Field Instructor Supervisor Signature (required) Date
Supervisor – Is a legal affiliation agreement needed between AU and the agency?: 1) ____ No, or 2) _____ Yes
______Director of Field Program Signature Date
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