For Division Use Only
Approved for:
___BSW
___MSW
___________________Date
_______________________Signature
University of Wyoming Division of Social Work Agency Interest Form
Official Agency Name_____________________________________________________
Program Name within Agency (as applicable)__________________________________
Complete Address:
____________________
_____________________
_____________________
Mailing Address (if different):
_____________________
_____________________
Phone number:_________________
Fax number:___________________
e-mail address:_________________
Web Site Address:______________
Executive Director Name and title:____________________________________________
Initial Contact for Field Placement:___________________________________________
Check the services provided or administered through your agency as well as populations
served:
__AIDS/HIV
__Advocacy
__Aging/Gerontology
__Adolescent/Children
__Community Planning
__Criminal Justice
__Cultural/Ethnic Diversity
__Disabilities
__Adult Education
__Intimate Partner Violence
__Family Services
__Emergency Assistance
__Gay Lesbian Bi Trans
__Health Promotion
__Homeless
__Mental Health
__Veterans
__People on Poverty
__Policy/ Legislation
__Prevention
__Public Welfare
__Legal Services
__Rehabilitation
__School Social Work
__Substance Abuse
__Victim Services
Check what the agency provides for students:
__Desk
__Stipend ___ Amount
__Phone
__ Computer
__Mileage Reimbursement
Stipend Criteria:__________________________________________________________
Check what is required from students:
__Background Check (type)________
__Immunizations (type) ___________
__Language Proficiency other than English
__Insurance (type)______________
__Drug Testing
__Specific Training or Courses
Check the appropriate funding source(s) for your agency:
___Non- profit
___Public ___Grant
___For Profit
8/11/2010
Field Office: (307)766-2710
Fax: (307) 766-6839
edoleizz@uwyo.edu
Does the agency have a specific procedure and or application process in selecting field
students and or completing requirements for placement? __Yes __No
If YES, please describe:______________________________________________________
_________________________________________________________________________
Provide a description of your agency and services. In this description include a statement
about the agency mission or philosophy. Attach brochures and/or other descriptive
materials regarding your agency. The description may be included in our Placement
Tracking system so that students may have access to it. You will be able to edit it.
What is your rationale for having social work students placed within your agency?
Describe several of the key learning opportunities that students might expect to have
within your agency, these may include work with individuals and families, groups,
administration, community organization, advocacy, policy, and /or legislation.
Will supervisors be granted comp time or work load adjustment for supervising
students? (minimum of 1 to 1 ½ hours of supervision per week)
___Yes ___No
Please List Qualified Potential Field Instructors (must have a Social Work degree)
________________________________________________________________________
(Name)
(Degree)
(Years of Post Degree Experience)
________________________________________________________________________
(Name)
(Degree)
(Years of Post Degree Experience)
Please list Potential Onsite Supervisors (experienced human service personnel who do not
have a degree in social work but would provide field supervision for students if there is
not a social work supervisor onsite)
________________________________________________________________________
(Name)
(Degree)
(Years of Experience)
________________________________________________________________________
(Name)
(Degree)
(Years of Experience)
Enter the number of students your agency can accept for the following categories:
Undergraduate
Graduate
___Fall/Spring (Sept-April; 16 hrs/wk)
___Summer (May-August; 35 hrs/wk)
8/11/2010
___Fall/Spring(Oct-April; 16 hrs/wk)
___Spring (Jan-April; 34 hrs/wk)
Field Office: (307)766-2710
Fax: (307) 766-6839
edoleizz@uwyo.edu
___Summer/Fall (May-Dec; 34hrs/wk
___Fall (Sept-April; 17 hrs/wk)
Person completing form_______________________
Position____________________________________
8/11/2010
Date:____________________
Field Office: (307)766-2710
Fax: (307) 766-6839
edoleizz@uwyo.edu