Agency Qualification Form

Please complete the following form to participate in our field placement program.

Agency Name
Program
Agency Address Agency Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Website
Phone Phone - ### - ### ####
Fax Fax - ### - ### ####
SW Director
SW Director email address
Training Director
Training Director email address
Training Director phone number Training Director phone number - ### - ### ####
Name(s) of LICSW Field Instructor(s) & their phone numbers
Total # of SW trainees
Number of Staff SWs

Please answer the following questions
Please answer the following questions	Yes	No
CORI check?	CORI check?Yes	CORI check?No
Stipends?	Stipends?Yes	Stipends?No
Medical Test?	Medical Test?Yes	Medical Test?No
Medical Form?	Medical Form?Yes	Medical Form?No
Car needed?	Car needed?Yes	Car needed?No
Home visits?	Home visits?Yes	Home visits?No
Travel reimbursement?	Travel reimbursement?Yes	Travel reimbursement?No

Race/Gender/Language Preference(s)
Mandatory meeting times and days
Other schedule requirements
How many Simmons student/s are you able to accept?
Year I
Year II
Advanced Standing
Setting

Setting Child & Family Services College Community Health Center Community-Based (services, IHT, center, etc) Court Day Care/Preschool Family Agency Hospice Hospital Inpatient Medical Hospital Outpatient Medical Housing In-patient Psych Nursing Home Out-patient Mental Health /Mental Health Clinic Partial Program Prison Residential School (public) School (SPED) School (residential) Shelter
Issue/Practice Area

Issue/Practice Area Aging Child Welfare Developmental Disabilities Domestic Violence Early Intervention End of Life Care Forensic Foster Care/Adoptions Health HIV/AIDS Homelessness Immigrants/Refugees LGBTQIA+ Mental Health Parenting Persistent Mental Illness Rape Crisis Substance Treatment Trauma
Client Population (Please be specific about special populations, demographics, and problem areas)

Client Population (Please be specific about special populations, demographics, and problem areas) Children 0-5 Children 6-12 Adolescents Adults Older Adults
Direct Practice

Direct Practice Individual Family Group Home-based Case Management Advocacy Program Planning Crisis Intervention Management Long-term Short-term Organization activities (committees, task force, etc) Community projects Other Other
What steps is the organization taking for the advancement of diversity, equity and inclusion with the organization and community? How can students contribute to this work and/or how are students supported in this work?
Description of program and training opportunities (If your agency has placements in more than one site or department, please include the program descriptions for all programs)
A majority of placements are 24 hrs/week following the School’s academic calendar. Placements begin in September.

Would you consider a:
Would you consider a:	Yes	No
2 day/week placements for 12 months	2 day/week placements for 12 monthsYes	2 day/week placements for 12 monthsNo
Other flexible schedule options?	Other flexible schedule options?Yes	Other flexible schedule options?No

Is your site accessible by public transportation

Is your site accessible by public transportation Yes No
If yes, please give directions
Suggestions regarding the type of learner who would do best in your agency
Additional comments regarding your agency and training program (please send any additional documentation that you feel will help us)
If student(s) are to work at a location other than your main office please list the name(s), address(es), and phone #(s) of this/these agency branches (schools, residences, shelters, clinics, etc.)
Field Days

Year I student field days are Monday, Tuesday, and Thursday
(unless other arrangements are made in advance, i.e. required team meetings).
Year II student field days are typically: Monday, Thursday, and one of the following

Year II student field days are typically: Monday, Thursday, and one of the following Tuesday Wednesday Friday
Please note: Field Instructors who have not already taken a Supervision Seminar, are required to do so. This requirement can be met by taking the seminar offered annually by Simmons or by any other school of social work.

Agency Qualification Form

Agency Qualification Form

How many Simmons student/s are you able to accept?

A majority of placements are 24 hrs/week following the School’s academic calendar. Placements begin in September.

Field Days