Bloomsburg  University
Social  Work  Program  Interview  Checklist/Pre-­‐Internship  Packet
Please   begin   to   complete   this   form   at   the   time   of   your   internship   interview,   collect   all   required  paperwork  and  submit  ALL  information  to  the  Coordinator  of  Field  Education/Field
Office  before  ___________.  Please  make  sure  to  keep  a  copy  of  this  form  and  all  paperwork   submitted   with   this   form   for   your   records .
All   paperwork   indicated   in   this   form   MUST   be   completed  prior  to  you  beginning  your  internship .   Please  attach  a  copy  of  your  resume  to  this   form.
***   Please   make   sure   to   submit   all   information   in   a   folder   with   your   name   on   it.
Additionally,  each  piece  of  paper  should  have  your  name  clearly  displayed  on  it.
Student  Intern  Name:____________________________________________________________
Student  Intern  E-­‐mail  Address:_________________________________________________
Agency  Name:_______________________________________________________________
Agency
Address:______________________________________________________________________
______________________________________________________________________________
Agency  Phone:  _________________________________________________________________
Field  Supervisor/  Field  Instructor/  Administrator:  __________________________
______________________________________________________________________________
E-­‐mail  address  of  Field  Supervisor/  Field  Instructor/Administrator:_______________________
Is   there   a   current   affiliation   agreement   with   Bloomsburg   University?   Check   BU   academic   internship  web  site:   http://internships.bloomu.edu/companyList.cfm
Yes          No
In  Progress
Comments:_____________________________________________________________________
______________________________________________________________________________
Does  the  agency  provide  liability  coverage  for  their  interns?     Yes             No
If  yes,  please  make  sure  to  obtain  a  letter  from  the  agency  administrator/  executive  director   indicating  that  the  agency  liability  policy  will  cover  you  as  the  intern  during  your  internship  at

the  agency.  This  letter  will  need  to  be  an  original  on  agency  letterhead  and  be  signed  by  the   field  instructor  as  well  as  the  agency  administrator.
If  no,  please  obtain  individual  student  liability  insurance.
Agency  Liability  Letter  Obtained
N/A
Yes     No
Does  the  agency  require?
Medical  Examination           Yes     No
Medical  Tests/  immunizations
Drug  Test
Yes
Yes
No
No
Other  Tests  (please  specify)         Yes     No
________________________________________________________________________
Other  requirements  (please  specify)       Yes     No
_______________________________________________________________________
Have  you  as  the  student  intern  applied  for  and  received  an  official:  (attach  a  copy  to  this  form)
PA  State  Police  Criminal  Record  Check       Yes     No
PA  Child  Abuse  History  Clearance
FBI  Clearance
Yes
Yes
No
No
Individual  Student  Liability  Insurance       Yes
Other   State
____________________________________________________________
No
(specify)
Criminal  and  Child  Abuse  Clearances       Yes     No
Comments:______________________________________________________________
________________________________________________________________________
Have  you  completed  a  509  form?  (this  form  can  be  found  on  the  BU  academic  internship  site)   http://internships.bloomu.edu/Form++509.pdf
Yes
No
Do   you   have   a   job   description   from   the   agency   specifying   your   job   duties   as   a   social   work   intern  at  the  agency?  (a  copy  must  accompany  the  509  form)
No
Yes

______________________________________________________________/_______________
____
Student  Intern                   Date
Date   completed   Form   and   packet   received   in   the   Social   Work   Field   Education   Office:
______________