Place of Employment Agency Placement Plan Questionnaire

Policy, Process, Criteria, and Application
For Practicum Placement at Place of Employment
(Work Site Placement)

Place of Employment Agency Placement Plan Questionnaire

This section of the application for practicum placement at a place of employment is to be completed by the Agency Contact or Proposed Practicum Instructor.

Policy, Process, and Criteria for Practicum Placement at a Place of Employement (Work Site Placement) can be found in the Practicum Education Manual at https://socialwork.wayne.edu/practicum/manual

Fields with asterisks (*) are required.

Name of Requesting Student *

Name of Agency *

Name of Agency Contact Person *

Title *

Telephone *

Fax

Email *

How large is the agency? (Number of clients, number of staff and level of staff e.g. BA., BSW, MSW, other professionals; attach agency brochures or other agency information, if available) *

Does the agency provide services in several sites? *

Yes

What types of services does the agency provide? (Families at risk, child welfare, schools, health care, mental health, policy, leadership, etc.) *

Who are the agency’s clients? (Client problems, age group, gender, ethnicity) *

Where will the student be assigned to do the practicum placement?

Address line 1 *

Address line 2

City *

State/province/region *

Postal/zip code *

Country *

Telephone *

Fax

Contact person (if different from practicum instructor)

What will be the student's practicum placement assignment/s? *

Proposed Schedule *

Will the assignments be different from the student’s job responsibilities? *

Yes

Who will be the student's practicum instructor? *

The practicum instructor should be one who does not present a conflict of interest or the appearance of a conflict of interest such as being a friend or a colleague of the student. An instance where the student is the executive director of the agency or is in a supervisory relationship with staff presents a conflict of interest.

Has this person previously supervised the student? *

Yes

Does this person have a BSW or MSW degree? *

Yes

If yes, how many years post degree work experience?

State of Michigan License Number *

How many years has the person been employed with the agency *

Is the proposed practicum instructor an approved practicum instructor for WSU *

Yes

Address of proposed practicum instructor (if different from that given for agency)

Address *

City *

State *

Zip Code *

Telephone *

Email *

Is the Agency an approved partner with Wayne State University School of Social Work? *

Yes

If not, an Application for Agency Participation is required before the application for a Place of Employment application will be considered. Please visit https://socialwork.wayne.edu/practicum to complete the application.

THE AGENCY AGREES TO PROVIDE THE APPROPRIATE PRACTICUM EDUCATION EXPERIENCE FOR THE STUDENT WHO IS A PRESENT EMPLOYEE, IF THE SCHOOL APPROVES PLACEMENT IN THE AGENCY.

Signature *

Date *