Agency Information

Thank you for providing the information requested below. Whether you are updating information, or applying to be a new field site, we appreciate your taking the time to complete this form. We invite you to send agency brochures or reports that provide additional information regarding your agency to: NCSSS Office of Field Education, CUA, Cardinal Station, Washington, DC 20064. Also feel free to contact us at 202-319-5457.

1. Please complete the agency information below:

Please complete the agency information below: Agency Name
Street Address
City
State
Zip
Phone
Fax
Internship Coordinator
Coordinator Phone
Coordinator Email
Coordinator's Agency Position
Coordinator Degree
Coordinator License
Agency Website Address

2. Below please provide additional information -- you have more room for writing than it looks like you do!

Below please provide additional information -- you have more room for writing than it looks like you do! (1) agency mission:
(2) population served:
(3) services provided:
(4) special training offered:

3. If agency has more than one site, please indicate site name, address and phone number:

If agency has more than one site, please indicate site name, address and phone number: 1
2
3
4

4. Please indicate information for the upcoming academic year:

Please indicate information for the upcoming academic year: Not sure yet; please write 1 if this is your choice.
Number of UNDERGRADUATE social work juniors you could accept (for an 8 hour/week Jan - April placement:
Number of UNDERGRADUATE social work seniors you could accept (min. supervisor's req: MSW + 2 yrs' experience):
Number of 1st year MSW students you could accept (min. supervisor's req: MSW + 2 yrs' experience):
Number of 2nd year CLINICAL students you could accept (min. supervisor's req: clinically licensed MSW):
Number of 2nd year CLINICAL HEALTH students you could accept (min. supervisor's req: clinically licensed MSW):
Number of 2nd year MACRO (= Social Justice & Social Change) students you could accept (min. supervisor's req: MSW earned at least 2 years ago):
Number of 2nd year COMBINED (CLINICAL/MACRO) students you could accept (min. supervisor's req: clinically licensed MSW for clinical; MSW, 2 years' exp for macro):
TOTAL NUMBER of students you can accept:

5. Your responses below will help ensure that any student we refer to you will have a schedule that fits your setting:

Your responses below will help ensure that any student we refer to you will have a schedule that fits your setting: Required internship hours (e.g. Wed. 9-11am for team meetings):
Ideal field schedule (e.g. 16 hours spread over 3 days/week, or 11am - 7pm to be available for after school sessions):
Indicate evening/weekend hours, if available (note that MSW-level social worker must be on duty when intern is on site):

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