Field Education Office
Agency Data Form
 The purpose of this form is to obtain pertinent details on the identified agency below for use by the UFV School of
Social Work and Human Services Field Education Office and current UFV Social Work and Human Services students
 The information gathered will be entered into a secure online database for SWHS students to learn more about
available agencies relevant to their field placement.
 Please kindly complete and e-mail this electronic form to lucki.kang@ufv.ca
 Thank you for your time!
AGENCY CONTACT INFORMATION
Agency Name:
Mailing Address:
City:
Province:
Postal Code:
Telephone:
Fax:
Web Site:
Prospective Agency Contact Person
Name:
Title:
Telephone:
Fax:
E-mail:
Is the Agency Administration aware and in support of Agency Staff providing field supervision to
UFV SWHS students?
Yes
No
1. a) Does the agency have a potential Field Instructor who holds either a BSW or MSW degree
with two or more years of social work experience?
Yes
No
b) If you answered YES, please identify whether this individual will act as a primary Field
Instructor or as a secondary Field Instructor:
Primary – willing and able to meet with student 1.5 hours per week and is responsible for
organizing the placement and supervising the student’s daily learning throughout the placement
Secondary – willing and able to meet with the student every 2 to 3 weeks and is available to
assist the student to integrate the social work theory and knowledge. This model is used if the
primary Field Instructor does not have a BSW or MSW degree.
c) If you answered NO, would the agency be willing to allow UFV to arrange for an external
social work consultant for the BSW field placement?
Yes
No
2.
Please include a brief description on the agency, including its Mission Statement, population
served, and services offered:
3.
Which of the following programs is most suitable for the agency and field placement
experience? Please select all that apply.
MSW
4.
4th yr BSW
3rd yr BSW
Diploma
Certificate
Please indicate the levels of generalist practice that your agency can provide. Please select all
that apply.
Micro (direct practice with individuals of families)
Mezzo (groups and interagency group meetings)
Macro (community development, policy, administration, or advocacy)
5.
Is the agency public or private not-for-profit?
Public
6.
Private Not-For-Profit
How many students can the agency accommodate per semester?
Fall semester: September to December
Winter semester: January to April
7.
Please check all special requirements that apply:
Criminal Records check at student’s
expense
Valid driver’s license required
Vehicle required
If so, will the agency reimburse for
mileage?
Yes
No
Second language required
please specify
Criminal Records check at agency’s
expense
Current First Aid or C.P.R required
Ability to accommodate disabilities
Immunization required
please specify
8.
9.
Are students required to work evenings or weekends?
Evening -
Yes
No
Weekend -
Yes
No
Scope of Social Work Practice. Please check all that apply.
Child Welfare
Elder Care
Health Care
Community Based Practice
Crisis Intervention
Family Services
Mental Health
Substance Abuse
End of Life Care
School Based Programs
Corrections
Gender Issues
Counselling
Community
Development
Domestic Violence
Youth Based Services
Sexual Abuse
Social Policy
Early Childhood Services
Vocation/Employment
Services
Advocacy
Immigrant Services
Educational Support
Housing/Homelessness
Developmental
Disabilities
Other, please specify
10.
Please list prior skills required of the student for success in the field placement:
11.
Please list expectations of the social work student during the field placement:
12.
Please list learning opportunities/activities/skills for social work students:
MASTER OF SOCIAL WORK DEGREE PLACEMENTS
13.
Please list leadership and supervision learning opportunities for MSW field placement
students:
COMMENTS
The UFV School of Social Work and Human Services Field Education Office thanks you for your interest in social work
education and for your time in completing this valuable form.
Should you have any questions or concerns, please contact:
Lucki Kang, MSW, RSW
Field Education Coordinator
School of Social Work and Human Services
University of the Fraser Valley
33844 King Road
Abbotsford BC
Ph: 604-864-4640 toll free: 1-888-7441 ext. 4640
E-mail: lucki.kang@ufv.ca