Placement Opportunity Application Form

Thank you for your interest in becoming a field placement site for the PSU School of Social Work. Our students spend 16 hours/week in their field placements and must be supervised by qualified field instructors. Please see the PSU School of Social Work's qualifications of Field Agencies and Field Instructors.

INSTRUCTIONS: Please complete this form on your computer, then press the SEND INFORMATION button at the bottom of the form. This emails your application to the PSU School of Social Work.

Your Name:

Your Phone:

Your Email:

Agency:

Program: (if applicable)

Street:

City: State: Zip:

Phone:

Website:

Brief Program Description:

Internship Opportunities:

Will you be the field instructor (requires SW degree) for this placement?

Yes
No

If no, please identify who the field instructor will be.

Name: 

Phone:

Email:  

How many PSU students can your program host?

1
2
3
More than 3

Are you willing to hold these spaces for PSU Social Work students?

Yes
No

What sequence(s) can your organization accommodate? (Please see Practice Sequence and Concentration Descriptions).

  Generalist (BSW and MSW 1st Year)
  Practice & Leadership with Communities and Organizations
  Clinical Social Work Practice

Fields of Practice -- please check all that apply:

  Addictions
  Child Welfare
  Corrections / Criminal Justice
  Developmental Disabilities
  Domestic Violence
  Family Services / Parenting and Early Childhood
  Healthcare
  Housing/Homelessness
  Immigrants and Refugee Services
  Mental Health
  Older Adult
  Public Assistance / Self Sufficiency (not Child Welfare)
  School Social Work
  Services to Veterans / Families

Primary Service Area

The Council on Social Work Education (CSWE) requires us to annually report the types of services provided by our field agencies. Please choose the one (1) category that best describes your agency's work.

Administration
Aging/Gerontological Social Work
Alcohol, Drug, or Substance Abuse
Child Welfare
Children/Youth
Clinical
Community Planning
Corrections/Criminal Justice
Developmental Disabilities
Family Services
Health
Housing Services
Immigrants/Refugees
Integrated Health
International
Leadership
Mental Health or Community Mental Health
Military Social Work
Military/Veterans
Nonprofit/Public Management
Program Evaluation
Public Assistance/Public Welfare (not Child Welfare)
Research
Rural
School Social Work
Social Policy
Trauma
Other (Please specify in text box below)

Population(s) served -- please check all that apply:

  Adolescents
  Adults
  Children
  Communities
  Families
  Older Adults
  Organizations

Do you have any culturally-specific programs?

Yes
No

If you do have culturally-specific programs, please describe below:

Are bilingual students preferred?

Yes
No

Are bilingual students required?

Yes
No

If bilingual students required, what language(s)?

Are there regular social services offered during the evenings that would allow a student to complete a majority of their 16 hours/week placement during evenings?

Yes
No

Are there regular social services offered on the weekends that would allow a student to complete a majority of their 16 hours/week placement during the weekend?

Yes
No

Does this placement require a driver's license?

Yes
No

Does this placement require a car?

Yes
No

What qualities/skills make an intern the best fit for your program?

What prompted you to offer a field placement at this time (e.g. postcard, personal
contact with SSW faculty, colleague referral, PSU SSW alumni status, other)?

Please check the appropriate box: (Your application will be e-mailed to the correct program option).

Distance Option - Ashland, Central Oregon, Eugene, Salem Cohorts (Jessica Hayes)
Portland Campus Program (Jessica Hayes)
Online Program (Jessica Hayes)

Thank you for taking the time to complete this form!