Office of Practicum Education Application for Agency Participation

We are always interested in forming relationships with new agencies. If you are part of a social work agency in the metro Detroit or surrounding area, and you would like to work with our social work students, please complete the Application for Agency Participation to be considered as a placement site.

Fields with asterisks (*) are required.

Agency Information:

Agency Name *

Department

Address line 1 *

Address line 2

City *

State/province/region *

Postal/zip code *

Country *

Agency Phone Number *

County *

Agency Administrator:

Full Name *

Agency Position/Title

Contact Person:

First name *

Last name *

Email *

Telephone (Ext.) *

Agency Position/Title *

Does your agency require an affiliation agreement? *

Yes

Practicum Instructor(s):

Practicum Instructors MUST have a Bachelor of Social Work or Master of Social Work degree and be Licensed (LBSW or LMSW). Those who want to serve as task supervisor do not need such credentials and may provided daily supervision to student(s); however, a social work degree holder with a License must provide a minimum of one hour weekly supervision to assigned student(s)

Full Name *

Email *

Telephone (Ext.) *

Please select degree type. Degree must be from a CSWE/CASWE accredited institution. Applicant must have a minimum of two years post degree experience *

License Number

Full Name

Telephone (Ext.)

Please select degree type. Degree must be from a CSWE/CASWE accredited institution. Applicant must have a minimum of two years post degree experience

License Number

Placement Classifications:

Placement Type *

Placement Environment *

Select the Curricular Year(s) of Potential Interns:

Please indicate the total number of students *

Please Select All that Apply *

BSW Part-time Seniors (January-August 16 hours per week)

BSW Senior (September-April 16 hours per week)

BSW WOW (September-April 16 hours per week) *Where Online Works- online program

MSW Foundation (September-April 16 hours per week)

MSW Advanced (September-April 16 hours per week)

MSW Advanced (September-April 24 hours per week)

Additional Comments

Agency Practice Area(s) :

Other:

Populations Served:

Other

Agency Schedule for Student Practicum Placement:

Shift start and end time *

Can you accommodate students during evening and/or weekend hours? *

Yes

Other comments regarding student schedule *

Agency Requirements:

Are interns required to participate in any training sessions *

TB Testing *

Not Required

Agency Expense

Student Expense

Background Check *

Not Required

Agency Expense

Student Expense

Finger Printing *

Not Required

Agency Expense

Student Expense

Drug Screen *

Not Required

Agency Expense

Student Expense

Other: Please provide any additional requirements for students.

Financial Stipends:

Does the agency provide financial stipends? *

Yes

Please indicate the dollar amount of the stipend and any specific requirements and/or conditions

Narratives:

Please review expectations for each curricular level in the Office of Practicum Education Manual at https://socialwork.wayne.edu/practicum/manual

What experiences will your agency provide to a BSW Senior Year/MSW Foundation Year intern? Include the type of assignments, the population, and any other relevant details. *

What experiences will your agency provide to a MSW Advanced Year Interpersonal Practice (IP or Micro) intern? Include the type of assignments, the population, and any other relevant details. *

What experiences will your agency provide to a MSW Advanced Year Innovation in Community, Policy, and Leadership (ICPL or Macro) intern? Include the type of assignments, the population, and any other relevant details. *

Please provide any relevant agency changes within the past 2 years or since the last agency application was submitted. *

Agency Website

Please feel free to contact the Office of Practicum Education with any questions or concerns.
Phone: 313.577.4446
Email: practicum_education@wayne.edu

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