Fillable Application For In-Agency3

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Application For In-Agency3

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Application for Internship in Agency of Employment
BA & MSWII: Due second Friday in April
MSWI: Due second Friday in June
I. Identifying Information:
Student Name: Date:
Field Level: BA MSWI MSWII Academic year of placement:
(check one)
II. Present Job Assignment:
A. Please type in the text box below a description of your present job assignment and the specific
circumstances of the assignment. Include:
• Job classification
• Job status (temporary/permanent; full time/part time); specify that probationary status in current
work assignment has been satisfactory completed.
• Length of employment
• Regular hours of employment
• Present job duties and a thorough description of functional tasks
• Names of those persons responsible for your direct supervision and for administration of the
agency.
1
III. Prior Experiences
A. If you have worked in other areas of the agency in addition to your present job assignment, include in the
textbox below, a brief description of those areas/units and the length of time in each, including months and
dates. If applicable, identify the unit and/or agency where you have had a prior BA and/or MSW level
internship. Provide a brief description of the internship experience, roles undertaken, and skills learned.
IV. Proposed Internship Experience
A. Please type in the text box below a written description of the proposed field placement assignment and the
specific circumstances of the proposed internship. Note: The proposed internship must be clearly
differentiated from current and past job assignments and must meet the curriculum requirements of the
social work program. Include the following:
• Proposed assignment (i.e. area or unit)
• Proposed work and internship days and hours, including planned workload modification to
accommodate internship hours. Also address how you will accommodate required classes and any
program seminars (Note: Consejo and Title IV-E seminars do not count toward field hours). Field
(MSW) and supervision seminars (BA) do count toward field.
2
B. Proposed MSW Field Instructor:
Please provide the name of the proposed MSW field Instructor who has no authority over you as an
employee.
Field Instructor Name: Title:
Email: Phone:
If the field instructor is new to Fresno State, attach a Field Instructor Profile form to this application. The
form can be found on the DSWE website at: http://www.fresnostate.edu/chhs/social-work/policies-
forms/fieldmaterials.html
C. Proposed Learning Assignments:
Refer to the Field Manual for your field level (BA, MSWI or MSWII) located on the DSWE website. Look up
the learning agreements and specify proposed assignments tailored to your proposed internship that meet
curriculum requirements specified in the learning agreements.
Professional Identity/Development (list at least 4 activities)
Professional Ethics- BA only (list at least 3 activities)
3
Generalist Practice (BA) or Multi-Systems Practice (MSWI & MSWII) (list at least 5 activities)
Evaluation Practice (list at least 3 activities)
The signatures below indicate agreement with the terms of this proposal and an understanding that the
arrangements agreed upon may not be changed without advanced approval from both the agency and the Field
Coordinator.
V. Signatures:
___________________________________________________________ ______________________________
Student Signature Date:
___________________________________________________________ ______________________________
Proposed MSW Field Instructor Date:
___________________________________________________________ ______________________________
Agency Administrator Date:
___________________________________________________________ ______________________________
Department of Social Work Field Coordinator Date:
4
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Application For In-Agency3

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Completed 28 May 2020

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