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1、Field Education Pre-Placement QuestionnaireInstructionsAny student requesting a field placement must fill out this form. Complete this form for all students who will be requesting a field placement in the fall (including worksite). Email form and your updated resume to: fieldbrynmawr.edu. Review the
2、 MSS Field Education Manual available at: http:/www.brynmawr.edu/socialwork/field.html Review NASW Code of Ethics available at: http:/www.socialworkers.org/pubs/code/default.aspRequirements Advanced Standing are in placement Summer, Fall, and Spring semesters. 1st year, 2nd year, and worksite studen
3、ts are in placement for both Fall and Spring semesters. Advanced Standing students are scheduled 22.5 hours per week x 10 week summer semester = 225 hours. 1st year students are scheduled 15 hours per week x 15 week semester = 225 hours per semester. 2nd year students are scheduled 22.5 hours per we
4、ek x 15 week semester = 337.5 hours per semester. Students requesting to complete an employment-based field placement (Worksite) should complete a “Proposal for Worksite Placement” form (see Field Education Website). Students must be registered for Field Education I-IV for each term they are in a fi
5、eld placement and the corresponding Foundation, Clinical Social Work and Community Practice, Policy and Advocacy class. Students requesting accommodations must present a letter from Access Services specific to field placement. Students should not request a field placement in an agency where they or
6、a family member has/is receiving services. Most agencies require a student to obtain Child Abuse & Criminal History Clearances, which include a state police and FBI clearance. Students may also be required to obtain a physical examination, drug and hepatitis B screening. The Field Education departme
7、nt cannot guarantee placements for students who have been convicted of misdemeanors and/or felonies and are unable to pass Child Abuse &/or Criminal History Clearances. Bryn Mawr Graduate School of Social Work and Social Research provides liability coverage to all students in field education.Deadlin
8、es DEADLINE FOR CONTIUING STUDENT PLACEMENT REQUESTSJANUARY 15 DEADLINE FOR ADVANCED STANDING PLACEMENT REQUESTS- MAY 15 DEADLINE FOR INCOMING STUDENTS PLACEMENT REQUESTS JULY 15 Field Education Bryn Mawr CollegeGraduate School of Social Work and Social ResearchPre-Placement QuestionnaireSTUDENT INF
9、ORMATION (Please print or type. Complete all that apply)STATUS:Full-TimePart-TimeFirst year Field2nd year Field Advanced StandingCONCENTRATION: Clinical Practice Community Practice, Policy & AdvocacyDEGREE:MSSMSS/MLSPMSS/MPHNameMailing addressCity/State/Zip CodeTelephoneHome:Work:Cell:E-Mail Address
10、Please note: Correspondence will be sent to your Bryn Mawr College email address. We advise that you check your email account throughout your placement for important information and reminders. It is your responsibility to forward your GSSWSR email to any personal/secondary email account.SPECIAL PROG
11、RAMS (Check below):Child & Family WellbeingHome and School VisitorOrganizational ManagementPlease read and complete the following section.Indicate most recent work experience (social work/human services related):_YesNoMost recent volunteer experience (Please describe):YesNoDo you have use of an auto
12、mobile for field placement?YesNoWill you be employed while in field placement? If yes, average # hour(s) per week YesNoDo you have any travel restrictions?YesNoWill you be able to obtain Act 33/34 clearances (and/or FBI fingerprinting) that are free of misdemeanors and felonies?YesNoAre you requesti
13、ng accommodations for your field placement? YesNoWhat additional considerations are most important to you in the selection of a field placement assignment such as location, etc.?Is there any information pertinent to your being assigned to a field placement that has not been identified in this form?
14、YesNoIf yes, please discuss the information during your interview with the field dept.Do you agree to abide by the NASW Code of Ethics in your field placement?YesNoAre you aware that violations to the Code of Ethics in field placement can lead to academic integrity charges?YesNoI agree to follow the
15、 GSSWSR Standards of Professional Behavior (attached)YesNoI agree to follow the GSSWSR policies and procedures regarding field placement.YesNoI understand that all computer hardware, software, network access, information and data provided to me as a social work student intern is the property of the agency in which I am placed and should be used for official agency purposes only. I will not use the agency computer systems for
