Social Work Field Agency Profile Form

Agency/Organization Name*

Address*

City*

State*

Zip Code*

Name of Contact Person*

Email Address (for contact person)*

Phone Number (for contact person)*

Fax Number (for contact person)

Agency Website*

Type of Organization

Public

Private, for profit

Private, not for profit

Other

Brief Description of Agency Mission/Services*If you would like to provide brochures, please email to Angelia Ham at aham@SBUniv.edu.

AGENCY PERSONNEL

Number of MSW's

Number of BSW's

Number of Master's Degrees in Related Field

Number of Bachelor's Degrees in Related Field

Level of Social Work Student Eligible for Practicum at Your Agency (check all that apply)

BSW

MSW

Describe your procedure for selecting practicum students (resume, interviews, etc.):

How much advance notice do you need to consider/accept students?

What options will you offer a practicum student in your organization? (Check all that apply.)

Concurrent (two semesters)

Block (one semester)

What times of day are students able to complete practicum hours? (Check all that apply.)

Mornings

Afternoons

Evenings

Weekends

AGENCY REQUIREMENTS OF STUDENTS (indicate where applicable)

Minimum # of hours/week (specify)

Specific times for attendance (specify)

Prior experience (specify)

Home visits (specify)

Can a student using public transportation meet requirements for your site?

Yes

No

Criminal background check required?

Yes

No

Drug screen?

Yes

No

Abuse/Neglect background check?

Yes

No

Is a formal orientation provided/required?

Yes

No

Immunizations/health verification?

Yes

No

Are there expenses the student will be responsible for?

Yes

No

If there are expenses for the student, please specify:

Please list any other conditions of the practicum experience the student may need to be aware of:

ADDITIONAL CONSIDERATIONS

Is financial support available for the student?

Yes

No

If yes, please check all that apply:

Stipend

Travel

If a stipend is provided, please indicate the amount.

Is training provided to students around issues of safety in the agency, with clients and the community served by the agency?

Yes

No

Is your organization equipped to provide practicum opportunities for an international student for whom English may be a second language?

Yes

No

Is your organization equipped to provide practicum opportunities for visually/hearing impaired students?

Yes

No

Is your organization equipped to provide practicum opportunities for students utilizing adaptive equipment?

Yes

No

If yes, please describe the adaptive equipment for which your organization is equipped.

PRACTICE AREAS

If you marked other above, please specify the other practice area(s) available in your organization.

SERVICES AND LEARNING OPPORTUNITIES
Please select the services offered/learning opportunities available at your organization. Check all that apply.

Please describe any other clinical services/learning opportunities.

Please describe any other community services/learning opportunities.

Please describe any other management services/learning opportunities.

LEARNING RESOURCES

What learning resources are available at your organization? Check all that apply.

Internet

Practice manuals

Professional journals

Professional research library

Published practice guidelines

Systematic reviews

DIVERSITY OF CLIENTELE SERVED BY AGENCY (Check all that apply)
Please indicate the clientele your agency serves in the following categories.

Age

Infant/Toddler

Preschool

Elementary

Adolescents

Young Adults

Adults

Older Adults

Ethnic Groups

Caucasian

African American

Asian

Hispanic

Native American

Other

Sexual Orientation

Gay

Lesbian

Heterosexual

Bisexual

Transgendered

Family Status

Step-Parent Families

Single Parent Families

Two Parent Families

Other family forms (grandparent, foster, etc.)

Socio-Economic Status

Poverty Level or Below

Average Income

Above Average Income

Gender

Male

Female

Residence

Urban

Suburban

Rural