Agency Contact Information

Contact Name:

Contact's Email:

Contact's Phone:

Is this the person student would also contact to interview for placement?

Yes

No, Please indicate:

Name:

Email:

Phone:

Agency Information

Agency Name:

Agency Street Address: City:

State: Zip:

Website:

Does the website provide valuable information about your agency for students?

Yes No

Agency Description

Please tell us your agency's purpose, client populations served, size, and anything else you would like us, or your potential students, to know to decide whether your agency would be a good field site.

What will students actually do in a placement at your agency? (Please be detailed as the students will read this part to decide whether they are interested in being placed at your agency and whether they want to interview with you.)

Possible Opportunities in (Select both if both apply):

Clinical Opportunities - Individuals and Families Concentration

Macro Opportunities - Macro Concentration

Populations Served for agencies selecting Individuals and Families Track:

Older Adults

Adults

Children/Youth/Families

Child Welfare

Supervision Available:

How many BSW's on staff?:

How many MSW's on staff?:

How many MSW's with 2 or more years experience working after obtaining MSW degree?

If your agency does not employ a degreed social worker, is there a social worker serving as a board member, consultant or in another related role who knows your agency well and would be willing to serve as a field instructor/supervisor for a student?

Placement Opportunities

Indicate how many students at each level your agency would be able to accept.

BSW:

MSW (1st year students):

MSW (2nd year and Advanced Standing students):

What hours do you have available to students?

Day:

Evening:

Weekend:

Do you currently have an MSU Denver Social Work student in field placement?

No

Yes, if so check all that apply:

BSW MSW First Year MSW Second Year/Advanced Standing

Have you ever had an MSU Denver Social Work student in field placement?

No

Yes, if so check all that apply:

BSW MSW First Year MSW Second Year/Advanced Standing

Agreements

I have read, and agree to, the Affiliation Agreement ( 57 KB) and will mail a signed copy to MSU Denver.

I have read and understand the mission and goals of the BSW Program at MSU Denver.

I have accessed the most recent version of the 2012-13 Field Manual PDF ( 1,241 KB). (Field Manuals are published in August before the start of the academic year. Check back to obtain the version relevant to you, if needed).

Comments: