Agency Information Form

Agency Name

Date

Agency Address

City

State

Zip Code

County

Agency Phone

Agency Fax

Agency Web Address (URL)

Agency Director Name

Program in which student will be placed.

Program(s) Name

Program Director

Address if different from main agency address

Telephone

Program Fax

Person completing this form (name and title)

Please review the Fieldwork Manual

Describe the purpose of your agency, populations served, services offered, and geographic community

This placement is an appropriate field placement for (check all that apply to your agency)

Introduction to Social Work (Sophomore, 1 semester, total 80 hours – 1 day per week), begin to understand agency base of practice and beginning work with clients

Theory and Practice of Social Work I and II (Junior, 2 semesters total 400 hours – 2 days per week), direct practice with individuals, families and small group

Theory and Practice of Social Work III (Senior, 1 semester – Fall, total 200 hours, 2 days per week), macro, indirect practice – community organization, administration, program development

Experiences that will be available for the student

Please list special needs for the placement (i.e. student must be available on specific days, work nights, have a driver’s license, have had prior experience with population)

Other requirements *

Please list any additional information you would like students or faculty to know about your agency

Please have the field instructor for this student complete a Field Instructor Application form and send a Professional Resume to

Linda Gilman

Director of Field Education
Ramapo College of New Jersey
505 Ramapo Valley Rd
Mahwah, NJ 07430
Or to lgilman@ramapo.edu fax 201-684-7257 ph. 201-684-7132

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Agency Information Form

Related Resources

Program in which student will be placed.