Application for Field Placement
Date________________
NAME______________________________________________ PHONE________________________
ADDRESS:_____________________________________________________________________________
Street City State Zip
CREDITS EARNED TO DATE:___________________ GPA:____________ College Rank: FR SO JR SR
COURSE: SWK 28902/1 38903/1 48605 48705 SEMESTER: FL SP SU
8:30-
9:50
10:00-
1.
Complete the following schedule listing other courses scheduled for the term of placement and outlining your anticipated hours of availability.
MON TUES WED THURS FRI
DATE APPLICATION REC’D:__________
8:00-9:50
10:00-11:50
DATE OF INTERVIEW:_______________
11:20
11:30-
12:50
12:00-1:50
DATE OF PLACEMENT:______________
DATE OF COMPLETION:_____________
1:00-
2:20
2:30-
3:50
4:00-
5:20
2:00-3:50
4:00-5:50
CHECKLIST FOR APPLICANTS FOR FIELD PLACEMENT
________ Application
________ Agreement
________ Auto Insurance
________ Driver’s License
________ Health Insurance
________ Tuberculin Skin Test
________ Hepatitis B Vaccine or Waiver
________ Resume’
2.
List three areas of practice interest or agency settings.
A.___________________________________________
B.___________________________________________
C.___________________________________________
Note A: Verification of a dependable source of transportation is required.
Note B: A copy of a typed resume must be submitted prior to any placement interview.
Note C: Professional liability, health, and automobile insurance must be secured.
__________________________________________
Student’s Signature
Revised 3/12/14

As an aspiring social work professional, the student acknowledges the range of standards prescribing professional behavior in the social work relationship. State law, agency auspice and professional ethics guide the student’s behavior in interactions with clients. Students are expected to be familiar with and adhere to the Code of Ethics of the National
Association of Social Workers.
Agency practice, pertinent to the field placement, requires particular sensitivity to the standards relating to confidentiality and client privacy.
The NASW Code of Ethics (Section II.H) states:
Confidentiality and Privacy – The social worker should respect the privacy of clients and hold in confidence all information obtained in the course of professional service.
1.
The social worker should share with others confidences revealed by clients, without their consent, only for compelling professional reasons.
2.
The social worker should inform clients fully about the limits of confidentiality in a given situation, the purpose for which information is obtained, and how it may be used.
3.
The social worker should afford clients reasonable access to any official social work records concerning them.
4.
When providing clients with access to records, the social worker should take due care to protect the confidences of others contained in those records.
5.
The social worker should obtain informed consent of clients before taping, recording, or permitting third party observation of their activities.
Information gained about clients during field placements remains governed by the rules of confidentiality even after the placement is terminated. Any violation of conduct relative to the professional code of ethics is subject to review and disciplinary action.
_______________________________________
Student Signature Date
_____________________________________
Faculty Supervisor Date

This letter acknowledges an application for social work field placement. In addition to specific course requirements as outlined in the syllabus or training contract, the student is expected to comply with the following general standards of conduct associated with the assigned field placement.
1.
Student application for field placement does not guarantee placement with a specific requested agency. Although an effort is made to match student interest with available qualified sites, the Field Placement Director is responsible for field placement assignments.
2.
Unless another arrangement has been specified, the student agrees to fulfill the time requirement for a field placement within the registered semester. Hours should be evenly distributed throughout the assigned semester.
The student will follow the agency calendar and must clear all absences or adjustment to schedule with the assigned agency supervisor.
3.
The student must demonstrate a responsible plan for getting to the agency site on time. If an auto is needed for field placement, adequate public liability insurance is required.
4.
The student will honor the agency dress code. It is the responsibility of the student to request clarification regarding appropriate dress.
5.
The student agrees to fulfill all commitments and complete assigned tasks described in the course syllabus and field training contract.
6.
No financial compensation should be expected or implied by the student. The generic work status of all students while in field placement is as a volunteer. The student is not eligible for either unemployment or disability compensation.
7.
The student must provide evidence of health and accident insurance. In the event of injury or illness incurred while on placement assignment, the student is personally responsible for payment of care provided or pursued.
8.
The Health Services Department requires that each student have a confidential medical history on file, including proof of immunizations/childhood diseases, a current Tuberculin skin test, and receipt or declination of the
Hepatitis B Vaccine.
9.
Professional liability insurance is required of all students in field placement assignment.
Semester________________________ Course SWK___________________ Hours Required_______
________________________________________ _______________________________________
Student Date Field Placement Director Date
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
Agency_________________________________________ State Date________________________
Agency Supervisor________________________________ End Date__________________________
STUDENT IMMUNIZATION – HEPATITIS “B”
Revised 3/12/14

UNIVERSITY OF RIO GRANDE
________________________________________ ______________________________________
Name Date
________________________________________
Department/School
________________________________________
Title
Student Yes ( ) No ( )
HEPATITIS “B” SERIES
#1________________________________________
Date Site RN Initial
INFORMATION ABOUT HEPATITIS B IMMUNIZATION
The Disease
Hepatitis B is a viral infection caused by the hepatitis B virus (HBV). Most people who get hepatitis B recover completely, but 1-2% die and approximately 5-10% become chronic carriers of the virus. Most of these carriers have no symptoms, but can continue to spread the disease to others. Some may develop chronic active hepatitis and cirrhosis of the liver. HBV also appears to be a causative factor in the development of liver cancer.
Immunization against hepatitis B can prevent acute hepatitis and also reduce illness and death from chronic active hepatitis, cirrhosis and liver cancer.
The Vaccine
Hepatitis B vaccine is non-infectious. The vaccine consists of highly purified hepatitis B antigen. It has been extensively tested for safety and efficacy. A high percentage of healthy people who receive the three doses of the vaccine achieve high levels of surface antibody and protection against Hepatitis B. Persons with immune system abnormalities have less response to the vaccine, but over half of those receiving it do develop antibodies. Full immunization requires three doses of vaccine over a six-month period although some persons may not develop immunity even after three doses. There is no evidence that the vaccine has ever caused hepatitis B. However, persons who have been infected with HBV prior to receiving the vaccine may go on to develop clinical hepatitis in spite of immunization. The duration of immunity is unknown at this time.
Possible Side Effects of the Vaccine
The incidence of side effects is very low. No serious side effects have been reported with the vaccine. A few persons experience tenderness and redness at the site of injection.
Low grade fever may occur. Headache, dizziness, nausea and mild fatigue have been reported. As with any vaccine the possibility exists that other rare adverse reactions may be identified with more extensive use.
IF YOU HAVE ANY QUESTIONS ABOUT HEPATITIS B OR THE VACCINE, PLEASE ASK THE
#2_________________________________________
EMPLOYEE HEALTH SUPERVISOR OR THE INFECTION CONTROL NURSE.
Date Site RN Initial
#3________________________________________
CONSENT FORM
I have read the above statement about Hepatitis B and the hepatitis B vaccine. I have had an opportunity to ask questions and understand the benefits and risks of hepatitis B immunization. I understand that I must have 3 doses of vaccine to develop immunity.
However, as with any medical treatment, there is no guarantee that I will become immune or that I will not experience an adverse side effect from the vaccine. I request that the vaccine be given to me or to the person named below of whom I am the parent or guardian.
___________________________________________ ____________
Signature of person receiving vaccine
Or Parent or Guardian
Date signed
Date Site RN Initial
HEPATITIS “B” WAIVER
I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I should receive the vaccination series at my own expense.
______________________________________________
Signature
_______________________
Date