UM SSW Field Education
UM SSW Field Placement
UM SSW Agency Application
Agency Name
»
Street Address
»
Street Address
(line 2)
City
»
State
»
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip
»
County
»
DC-Washington DC
MD-Allegany
MD-Anne Arundel
MD-Baltimore City
MD-Baltimore
MD-Calvert
MD-Caroline
MD-Carroll
MD-Cecil
MD-Charles
MD-Dorchester
MD-Frederick
MD-Garrett
MD-Harford
MD-Howard
MD-Kent
MD-Montgomery
MD-Prince George's
MD-Queen Anne's
MD-St. Mary's
MD-Somerset
MD-Talbot
MD-Washington
MD-Wicomico
MD-Worcester
VA-FREDERIC
VA-CLARKE
VA-LOUDOUN
VA-WINCHESTER
VA-ARLINGTON
VA-FAIRFAX
VA-ALEXANDRIA
VA-FALLS CHURCH
VA-PRINCE WILLIAM
VA-MANASSAS
VA-MANASSAS PARK
VA-WARREN
VA-Fauquier
PA-PHILADELPHIA
PA-DELAWARE
PA-CHESTER
PA-LANCASTER
PA-YORK
PA-ADAMS
PA-FRANKLIN
PA-FULTON
PA-BEDFORD
PA-SOMERSET
PA-FAYETTE
PA-GREENE
PA-MONTGOMERY
DE-NEWCASTLE
DE-KENT
DE-SUSSEX
Phone Number
»
(include area code)
Fax Number
»
(inlcude area code)
Agency Website Address
Name of Administrator
»
Intern Coordinator
»
Intern Coordinator Phone
»
Intern Coordinator Email
»
Agency Mission
»
Is this agency licensed/accredited
by any governing authorities?
»
Yes
No
Please list type of accreditation and year
Which of the Following Best
Describes Your Setting and Services
»
School
Clinic
Agency
Hospital
In-Home Services
In-Patient Services
Out-Patient Services
Residential
Community Based
Legislative/Policy
Other
*
*
If Other Selected Above, Please Specify
In General, What is the Focus of the
Services Provided (check as many as apply)
»
Aging
Adult
Families/Children
Low Income
Homeless
Mental Illness
Substance Abuse
Health
Organizational Development
Maternal and Child Health
Employee Assistance
Hospice and Bereavement
Community Organization
Program Development
Advocacy
Social Policy
Legislation
Fundraising
What Type Of Organization is the Agency
»
Non Profit
Private Non-Profit
Private For Profit
What are the Days and Hours of Operation
»
Do Social Work Students Serve
Your Agency at a Single or at Multiple Sites
Single
Multi
If Multiple Sites, Please provide additional information.
Add Multiple Sites
Please list intern responsibilities here:
»
(Please try to include the following in your description as this will make it easier for your interns to become licensed in the future: "Clinical Social Work Services", "Perform assessments", "Diagnosing" and "Providing counseling or psychotherapy").
What Type of Social Work Activities Should a Student Expect to Have if Placed in Your Agency (check as many as apply)
»
Individual Therapy
Family Therapy
Group Therapy
Discharge Planning
Case Management
Community Outreach
Client Education
Advocacy
Legslative Activity
Community Organization
Program Management
Please Describe Any Other Activities Not Mentioned Above
Please check off any of the following applicable requirements or benefits:
Background Check Required
Drug Screening Required
TB Test Required
Drivers License Required
Personal Car Required
Reimbursement for work related expenses
Agency Car Provided
Free Onsite Parking
Do You Address the Issue of
Personal Safety in Your Orientation for Students
»
Yes
No
Do You Offer a Stipend to Students
»
Yes
No
What is the Amount?
Use annual figure; ie. 2200
$
Has your agency supervised UM SSW students previously?
»
Yes
No
If yes, when was the first time? (enter year, ie. 2000)
Please Identify Your Preference(s) for Student Field Placement Days and Hours
»
Foundation (First Year) Student(s)
Yes
No
Monday/Wednesday
Tuesday/Thursday
Other, Please Specify or note
No Preference
Advanced (Second Year) Student(s)
Yes
No
Tuesday, Wednesday, Thursday
Other, Please Specify
Do You Accept Extended Students (Advanced students who are in the field 2 days a week from September through July)
»
Yes
No
Can You Offer Supervised Field Instruction on the Weekends or in the Evenings
»
Yes
No
If Yes to Above, Please Explain
How Many Students are you Willing to Accept From Our Program
»
Foundation (1st Year)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Advanced (2nd Year)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
How Many From Other Programs
»
Other Social Work Programs
(Graduate and Undergraduate)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Other Programs
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
How Many Social Workers are There Within the Agency Who Are Eligible and Available to be Field Instructors
»
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Please Describe Anything Else you Would Like Your Student to Know About a Field Placement at Your Agency. Please include:
Particular Expectations, Prefences, Desired Skills and /or, Opportunities
Name of Person Submitting This Form
»
Title of Person Submitting This Form
»
Phone Number of Person Submitting This Form
»
Email of Person Submitting This Form
»
I have reviewed all the information provided, and to the best of my knowledge the information submitted on this application is accurate.
»
Yes
No
© 2024 University of Maryland, Baltimore. All rights reserved.
Site Map
Privacy
Web Accessibility
Web Feedback
Non-Discrimination
Core Values
Directory
