Home School of Social Work: Field Education

Wednesday, April 23, 2014

Placement Opportunity Application Form

Thank you for your interest in becoming a field placement site for the PSU School of Social Work. Our students spend 16 hours/week in their field placements and must be supervised by qualified field instructors. Please see the PSU School of Social Work's qualifications of Field Agencies and Field Instructors.

INSTRUCTIONS: Please complete this form on your computer, then press the SEND INFORMATION button at the bottom of the form. This emails your application to the PSU School of Social Work.

Your Name:

Your Phone:

Your Email:

Agency:

Program: (if applicable)

Street:

City: State: Zip:

Phone:

Website:

Brief Program Description:

Internship Opportunities:

Will you be the field instructor (requires SW degree) for this placement?

Yes
No

If no, please identify who the field instructor will be.

Name: 

Phone:

Email:  

How many PSU students can your program host?

1
2
3
More than 3

Are you willing to hold these spaces for PSU Social Work students?

Yes
No

Can you host an Advanced Standing Student? (Advanced Standing students begin their field placement in the summer and continue through the following June)

Yes
No
Maybe

What sequence(s) can your organization accommodate? (Please see Practice Sequence and Concentration Descriptions).

  Generalist (BSW and MSW 1st Year)
  CBP (MSW 2nd Year)
  DHS (MSW 2nd Year)
  SSAL (MSW 2nd Year)

Fields of Practice -- please check all that apply:

  Addictions
  Child Welfare
  Corrections / Criminal Justice
  Developmental Disabilities
  Domestic Violence
  Family Services / Parenting and Early Childhood
  Healthcare
  Housing/Homelessness
  Immigrants and Refugee Services
  Public Assistance / Self Sufficiency (not Child Welfare)
  School Social Work
  Services to Veterans / Families

Primary Service Area

The Council on Social Work Education (CSWE) requires us to annually report the types of services provided by our field agencies. Please choose the one (1) category that best describes your agency's work.

Administration
Aging/Gerontological Social Work
Alcohol, Drug, or Substance Abuse
Child Welfare
Community Planning
Corrections/Criminal Justice
Developmental Disabilities
Domestic Violence or Crisis Intervention
Family Services
Group Services
Health
Housing Services
International
Mental Health or Community Mental Health
Military Social Work
Program Evaluation
Public Assistance/Public Welfare (not Child Welfare)
Occupational
Rehabilitation
School Social Work
Social Policy
Other (Please specify in text box below)

Population(s) served -- please check all that apply:

  Adolescents
  Adults
  Children
  Communities
  Families
  Older Adults
  Organizations

Are bilingual students preferred?

Yes
No

Are bilingual students required?

Yes
No

If bilingual students required, what language(s)?

Are evening hours available?

Yes
No

Are there regular social services offered on the weekends that would allow a student to complete a majority of her/his 16 hours/week placement during the weekend?

Yes
No

Does this placement require a driver's license?

Yes
No

Does this placement require a car?

Yes
No

Additional Comments

Please check the appropriate box: (Your application will be e-mailed to the correct person).

Distance Option - Ashland, Central Oregon, Eugene, Salem Cohorts (Thet Mar Win)
Portland Campus Program (Jessica Hayes)

Thank you for taking the time to complete this form!