Agency Information Form
College of Community and Public Affairs
Department of Social Work
Agency Contact Information
Agency
Contact Person
Phone
E-mail
Phone
Fax
Agency Name
Street Address
City and Zip
County
Web Address
Agency/Placement Description
Agency
Classification
(you may select more than
one; please indicate the
agency’s primary
classification)
[ ] Aging/Gerontological Social
Work
[ ] Alcohol, Drug, or Substance
Abuse
[ ] Child Welfare
[ ] Community Planning
[ ] Corrections/Criminal Justice
[ ] Family Services
[ ] Group Services
[ ] Health
[ ] Occupational/Industrial Social
Work
[ ] Intellectual Disability
[ ] Mental Health or Community
Mental Health
[ ] Public Assistance/Public
Welfare
[ ] Rehabilitation
[ ] School Social Work
[ ] Other
Please indicate in the space below information in regards to your agency. This does not need to be a complex,
detailed statement but should give students a rough estimate of what it is they should expect if they were to intern
with your agency. (i.e. types of clients, types of services provided, types of placement – clinical, mezzo, macro)
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Agency Information Form
College of Community and Public Affairs
Department of Social Work
Please describe in some detail what a social work student will do as part of your organization (i.e. what a typical
day/week would be like, what kind of learning opportunities would they have working with systems of different sizes?
What kind of skills would they gain at your agency?)
Working with
Individuals
Working with
Families
Working with
Groups
Working with
Communities
Working with
Organizations
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Agency Information Form
College of Community and Public Affairs
Department of Social Work
Please list any additional or special requirements that are required for your agency in the space below (i.e.
background checks, additional applications, TB testing, drug testing)
Placement Information
Transportation of
Clients
Accessible by
Public
Transportation
Vehicle Required
Number of Students
Accepted
Stipend Offered
[ ] Yes
[ ] No
Summer Hours
[ ] Yes
[ ] No
Weekend or Evening
Hours
Mileage
Reimbursement
[ ] Yes
[ ] No
[ ]1
[ ]2
[ ]3
[ ] Other (please specify)
[ ] Yes
[ ] No
Types of Students
Taken
Stipend Amount
Summer Block
Option
(465 hours over the summer)
Working Hours
[ ] Yes
[ ] No
[ ] Yes
[ ] No
[ ] Yes
[ ] No
[ ] First Years
[ ] Second Years
[ ] Both
$
[ ] Yes
[ ] No
Other Remarks
Feel free to write any additional comments in the space below pertaining to your agency or the internship.
We try to be flexible and meet a student’s needs.
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Agency Information Form
College of Community and Public Affairs
Department of Social Work
Current Field Instructors
Name
Credentials
E-mail
[ ] MSW
[ ] LMSW
[ ] LCSW [ ] LCSW-R
[ ] Other (please indicate)
Name
Credentials
E-mail
[ ] MSW
[ ] LMSW
[ ] LCSW [ ] LCSW-R
[ ] Other (please indicate)
Name
Credentials
[ ] MSW
[ ] LMSW
[ ] LCSW [ ] LCSW-R
[ ] Other (please indicate)
Phone
E-mail
[ ] MSW
[ ] LMSW
[ ] LCSW [ ] LCSW-R
[ ] Other (please indicate)
Name
Credentials
Phone
E-mail
Name
Credentials
Phone
Phone
E-mail
[ ] MSW
[ ] LMSW
[ ] LCSW [ ] LCSW-R
[ ] Other (please indicate)
Phone
Current Task Supervisors
Name
E-mail
Phone
Name
E-mail
Phone
Name
E-mail
Phone
Name
E-mail
Phone
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