FIELD EDUCATION
Request for MSW FOUNDATION Field Placement
School of Social Work - University of Pittsburgh
Instructions
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Complete this form to request a foundation field placement.
Attach one copy of a resume. An electronic copy will be requested by the field advisor.
Complete Student Agreement/Release of Information Form (completed upon admission to the Program)
Submit these materials via mail or in person to room 2129 Cathedral of Learning, Pittsburgh, PA 15260 (or via email at
sswfield@pitt.edu).
Review the MSW Field Education Student Handbook available at:
http://www.socialwork.pitt.edu/downloads/MSW%20FIELD%20HANDBOOK.pdf
Requirements
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First year part-time student internships will begin in June.
First year full-time student internships will begin in October.
Students on provisional or probation status must be approved for field placement.
Students requesting to complete an employment-based field placement should complete that specific form (see
Field Education Website).
Students must be registered for field placement credits for each term they are in a field placement.
Students must pay the malpractice premium before starting field placement.
Students requesting accommodations must present a letter from DRS specific to field placement.
Students should not request a field placement in an agency where they or a family member has/is receiving
services.
Deadlines
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DEADLINE FOR SPRING TERM PLACEMENT REQUESTS—OCTOBER 15
DEADLINE FOR SUMMER TERM PLACEMENT REQUESTS-MARCH 13
DEADLINE FOR CONTINUING STUDENTS FALL TERM PLACEMENT REQUESTS APRIL 25
DEADLINE FOR INCOMING STUDENTS FALL TERM PLACEMENT REQUESTS –
JULY 15
Revised 2/6/2016
FIELD EDUCATION
Request for MSW FOUNDATION Field Placement
School of Social Work - University of Pittsburgh
MSW STUDENT INFORMATION
(Please print or type. Complete all that apply)
REQUEST FOR PLACEMENT TERM:
Fall
Spring
Summer
Name
Mailing address
City/State/Zip Code
Telephone
Home:
Work:
Cell:
E-Mail Address
Please note: important correspondence will be sent to your University of Pittsburgh email address. We advise that
you check your University email account throughout your placement for important information and reminders. It is your
responsibility to forward your University email to any personal/secondary email account.
STATUS:
Full-Time
Part-Time
Advanced Standing
CONCENTRATION:
Direct Practice
COSA
CERTIFICATE PROGRAM (Check below):
CYF Certificate
Gerontology
Home and School Visitor
Human Services Management
Mental Health Certificate
Please read and complete the following section.
Have you applied to the HPPAE or CWEL Program? If yes, which one:
Yes
No
Are you pursuing a joint degree? If so, please note the progra m.
Yes
No
Do you have previous work experience (social work related)?
Yes
No
Previous field placement assignment as an undergraduate (Please describe):
Yes
No
Do you have use of an automobile for field placement?
Yes
No
Will you be employed while in field placement? If yes, average # hour(s) per week
Yes
No
Will you be able to obtain Act 33/34 clearances (and/or FBI fingerprinting) that are free of misdemeanors and felonies?
Yes
No
Are you requesting accommodations for your field placement?
Yes
No
What are your preferences for field placement (population, social issues, field of practice, type of setting)? (Complete atta ched pages)
What additional considerations are important to you in the selection of a field placement assignment such as location, etc.?
Is there any information pertinent to your being assigned to a field placement that has not been identified in this form? If
yes, please discuss the information during your interview with your field advisor, or attach a written discussion to this form.
Yes
No
Do you agree to abide by the NASW Code of Ethics in your field placement?
Yes
No
Are you aware that violations to the Code of Ethics in field placement can lead to academic integrity charges?
Yes
No
I agree to follow the School of Social Work’s policies and procedures regarding field placement.
Yes
No
I understand that all computer hardware, software, network access, information and data provided to me as a social work stude nt intern is the
property of the agency in which I am placed and should be used for official agency purposes only. I will not use the agency computer systems for
personal or non-agency business related purposes.
STUDENT SIGNATURE:
DATE:
TERM(S) OF FIELD PLACEMENT
Fall - AY
Revised 2/6/2016
Spring - AY
BELOW FOR FIELD EDUCATION OFFICE ONLY:
Summer - AY
YOUR SELECTED INTERESTS WILL ASSIST IN THE MATCHING PROCESS
AGENCY/SITE SETTING - CHOOSE YOUR TOP THREE (3)
Administrative Unit
Advocacy
Educational Unit
Elder Care
Inpatient Unit
Interdisciplinary
Rural
School-Based Mental
Health
After-School Program
School Social Work
Substance Abuse
Business
Community-based Health Care
Community-based Social Service
Emergency / Crisis Center
Employee / Student Assistance
Faith-based Organization
Community-based Mental Health
Family Service
Community-based Organization
Government
Multicultural Organization
Nursing Home
Outpatient Mental Health
- Adult
Outpatient Mental Health
- Child
Psychiatric Hospital
Community Center
Correctional
Court / Justice System
Day Treatment Program
Domestic Violence
Health Care
Homeless
Hospice
Hospital
Inpatient Mental Health
Rehabilitation Program
Residential Correctional
Residential Treatment – Adult
Residential Treatment – Child
Respite Care
Urban
Volunteer-Based
Program
Other:
AGENCY/SITE CHARACTERISTICS - CHOOSE YOUR TOP THREE (3)
Abuse & Neglect
Adoption
Adventure Education
Advocacy
AIDS & HIV
Alzheimer’s / Dementia
Child Welfare
Community Development
Crisis Intervention
Death & Dying
Developmental Disabilities
Domestic Violence
DSM IV Disorders
Eating Disorders
Elderly
Emotionally Disturbed
Family Systems Treatment
Foster Care
Gay / Lesbian / LGBT Issues
Health Care
Homelessness / Housing
Infant Mental Health
Immigration/Refugee Issues
Job Preparation & Development
Juvenile Delinquency
Legal Issues / Systems
Legislative Issues
Maternal & Child Health
Mental Health / Illness
Oppression & Injustice
Parenting
Parole / Probation
Pervasive Development Disorders
Physical Disabilities
Poverty
Pregnant Teens/Parenting
Protective Services
Public Welfare
Race & Social Problems
Reproductive Issues
School Social Work
Sexual Abuse & Assault
Special Education
Social Justice
Substance Abuse
Suicide Prevention
TITLE IV E
PRACTICE SKILL AREA - CHOOSE YOUR TOP THREE (3)
Advocacy
Assessment & Evaluation
Behavior Modification
Board Development/
Governance
Budgeting
Case Management
Committees / Task Force
Community Development
Community Outreach
Couples Treatment
Crisis Intervention
Data Collection
Discharge Planning
DSM IV (Diagnostic work)
EAP counseling
Individual Treatment
Legislative Advocacy
Mediation
Needs Assessment
Foundation Work
Fundraising
Grant Writing
Grassroots organizing
Group / Family Treatment
Information and Referral
In-home Intervention
Planning/Program Evaluation
Policy Analysis & Development
Prevention
Program Administration
Program Development
Public relations/marketing
Report Writing/Recording
Research and Analysis
Service Provision
Team Building/Coalition
Volunteer / HR
recruitment
Other:
POPULATION PREFERENCE - CHOOSE YOUR TOP TWO (2)
Children
Adolescents
Adults
Young Adults
Revised 2/6/2016
Mid-Life Adults
Elderly
Men
Women
Families
Couples
Groups
Individuals
No Preference
Other (specify)
FIELD PLACEMENT & AGENCY PREFERENCE
All placements must be arranged by the Office of Field Education. Students must not initiate contact with any
agency to seek a placement within that agency without prior approval of the Office of Field Education. Any
placement initiated without the knowledge of the field education staff will not be approved.
HOW TO SELECT APPROVED AGENCIES
Go to www.fieldedlink.pitt.edu. Click on the Agency Placement Listings, and follow the search criteria directions to
generate a list of agencies you are interested in being considered for field placement. These choices should match
the information contained in this request form. Please be as specific as you can. In addition to the agency list, you
may also add comments that describe the types of agencies or experiences that interest you.
Although we cannot guarantee that you will be placed in one of your preferred programs/agencies, this information
will be used to determine an appropriate field placement.
AGENCY NAME/LOCATION: (List Top 3 Choices)
Comments:
1.
2.
3.
ADDITIONAL COMMENTS-
This form was created in consultation with the North Central Field Education Consortium.
Revised 2/6/2016