Division of Social Work
ATTN: Field Education Program
6000 J Street, MRP 4010
Sacramento, CA 95819-6090
Phone: (916) 278-6943 Fax: (916) 278-7167
www.csus.edu/hhs/sw/index.html
Instructions: If your agency is interested in accepting one or more social work students for purposes of their
professional development, please complete this application and scan/email to ryan.jones@csus.edu, fax to the
number above, or mail to the address above.
Agency Information
Today’s Date ______________________________
Formal Agency Name:
Program/Site:
Physical Address*:
City:
Website:
County:
State:
Zip:
*If your agency has multiply programs/sites, please list your main office here and attach a separate sheet for other locations.
Main Contact Person
This person will act as the point of contact for the Agency application process.
Name:
Phone: (
)
Title:
Fax: (
)
Email
Legal Signatory for the Internship Agreement (MOU)
This is the person authorized to enter into Agreements or Contacts on behalf of the Agency – usually a CEO, Director, Manager, Supervisor, etc. If not known, mark
“TBD” and provide information when available.
Name:
Phone: (
)
Title:
Fax: (
)
Email
Contact Person for Student Interviews
This is the person the student will contact to schedule the interview for their Field placement - If not known, mark “TBD” and provide information when available..
Name:
Phone: (
)
Title:
Best Time to Call:
Email
BASW & MSW Field Placements
The agency will be able to offer field placements to students at the following levels of preparedness:
(Check all that apply and indicate # of students for each)
(
)Advanced Level (MSW II students)
# of students _____
( )Foundation Level (BASW & MSW I students)
# of students with 0-2 years previous experience in
human services _____
# of students with 3-5 years previous experience in
human services _____
# of students with more than 5 years previous
experience in human services _____
Revised Mar 2016
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Field Instructor / Task Supervisor Information
Please identify the professional social workers (must have an MSW) employed by your agency, regardless of
their work site location, who are available, qualified and willing to provide field instruction to the social work
students placed in your agency. Please attach an additional sheet if necessary. Note: Field instructors listed on
this application must complete the Field Instructor Application Form and attend Field Instructor Training.
Date Received
Field Instructor
Phone
Email Address
On-site?
MSW/LCSW
Degree
Name
( )
( )Yes ( )No
( )
( )Yes ( )No
( )
( )Yes ( )No
If there are no professional social workers available, is your agency willing to A) find and sign an agreement
with a professional social worker outside your agency to provide on-site field instruction to a student(s) and B)
designate a staff person to act as Task Supervisor who will provide daily on-site task supervision and
monitoring to the student(s)? ( )Yes ( )No
Task Supervisor Name:
Title:
Task Supervisor Name:
Title:
Phone: (
Email:
Phone: (
Email:
)
)
Agency Profile
1. Sector (Check only one): ( )Non-Profit ( )For-Profit ( )Public/Government ( )Educational Inst.
If a K-12 school, is PPS supervision available? ( )Yes ( )No
2. Would your agency be able to offer a stipend for BASW students?
MSW students?
(
(
)Yes (
)Yes (
)No
)No
3. Does the agency require that a student have a vehicle for placement-related duties? (
4. Does your organization use volunteers? ( ) Yes ( )No
If yes, does the organization have a policy covering volunteers? (
5. Does the agency require fingerprints and/or a background check? (
6. Does the agency require health checks and/or vaccinations? (
)Yes (
)Yes (
)Yes (
7. Does the agency bill for 3rd party payments (includes Medi-Cal)? (
)Yes (
)No
)No
)No
)Yes (
)No
Note: Agencies that bill for clients seen by students are expected to provide students a stipend in recognition
that the work of students is producing monetary resources for the agency.
8. Does the agency prefer bilingual students to perform client services? (
If yes, specify language(s). ____________
)Yes (
9. Does the agency offer evening and/or weekend hours for field placement? (
)No
)Yes (
10. Does the agency require an early start for training purposes? ( )Yes ( )No
Note: Students begin field placement the 2 nd week of the Fall semester.
Revised Mar 2016
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)No
)No
Agency Clientele
1. Check the primary ethnic majority of the
agency’s client population:
(
(
(
(
(
(
(
2. Check the primary population(s) served by the
agency:
)African American
)Asian / Pacific Islander
)Caucasian
)Latino
)Native American
)All
)Other (specify) _______________________
(
(
(
(
(
(
(
(
(
(
)Children
)Adolescents
)Adult Men
)Adult Women
)Older Adults
)Families
)Disabled
)Immigrant
)Lesbian, Gay, Bisexual, Transgender (LGBT)
)Other (specify) _________________________
Agency Service Areas
Check the primary service area(s) of practice in the agency:
(
(
(
(
(
(
(
)Child Welfare (CPS, foster care, adoptions, etc.)
)Mental Health
)Health or Medical
)School-Based
)Disability or Rehabilitation
)Criminal Justice, Corrections or Probation
)Welfare, Employment Assistance or Social Services
(
(
(
(
(
(
(
)Cultural or Immigrant Services
)Alcohol, Drug or Substance Abuse
)Aging or Gerontology
)Homelessness or Poverty
)Social Justice
)Victim Services
)Other (specify) __________________________
Agency Practice Modalities
Check the level of practice & modality emphasis in which students get actual experience:
Level of Practice
Level of Practice
Level of Practice
( )Direct (micro)
( )Indirect (meso)
( )Indirect (macro)
Modality Emphasis
Modality Emphasis
Modality Emphasis
(Please check all that apply)
(Please check all that apply)
(Please check all that apply)
( )Case Management
( )Counseling / Therapy
( )Advocacy
( )Group Work
( )Outreach
( )Other (specify)
_______________________
( )Administration
( )Supervision
( )Other (specify)
_______________________
( )Policy Development
( )Community Organizing
( )Planning
( )Evaluation
( )Lobbying
( )Advocacy
( )Other (specify)
________________________
Thank you for completing and returning this form.
Sacramento State requires a Field Placement Agreement be signed in order to establish your agency as an approved
facility/program for Social Work Field Instruction. Upon receipt of this application, the Field Administrative Assistant will
notify the Procurement and Contracts Office to send the Field Placement Agreement directly to the Legal Signatory or main
contact person listed on this application unless otherwise noted.
If you have any questions, please feel free to contact the Director of Field Education, Mimi Lewis at mimi.lewis@csus.edu or
Field Administrative Coordinator at ryan.jones@csus.edu.
Revised Mar 2016
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