Agency Information Survey

Thank you for providing the information requested below. Feel free to contact us at 202-319-5457. After receiving this information, we will contact you to set up a time to meet you at your agency to learn more about your agency and your internship program.

Question Title

* 1. 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

Question Title

* 2. 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:

Question Title

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

Question Title

* 4. 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:

Question Title

* 5. 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):

33% of survey complete.