Name: ______

The CatholicUniversity of America

NationalCatholicSchool of Social Service

Office of Field Education

Washington, DC 20064

202-319-5457

INTERNAL ADVANCED YEAR FIELD INFORMATION (Student Name)

  1. List up to 4 agencies you are interested in for your advanced placement (in order of preference). If you will be applying for (1) an Employment-based Internship or (2) aWork Residency Internship, indicate that below. Please arrange to meet with Dr. Roslynn Scott-Adams or Ms. Allyson Shaffer to discuss either of these options.

If you are suggesting that we affiliate with a new agency, we recommend that you FIRST arrange to meet with one of us in the Office of Field Education. We can tell you whether we have had an affiliation with the agency, and talk about our affiliation requirements. Then, (1) verify that there is a qualified MSW interested in supervising, (2) have the internship coordinator call us, and (3) follow up with us to make sure the required paperwork, which can be found at: has been completed.

1st Choice:______

2nd Choice:______

3rd Choice:______

4th Choice:______

  1. Are you interested in being considered for federal work-study (FWS) in the coming year? __ Yes __ No

If yes, next year you must (1) be full-time (for purposes of FWS, this means registered for 12 credits/semester; (2) show financial need; (3) submit the FAFSA as early as possible, and (4) be placed at a non-profit agency where you will not engage in lobbying. This funding is very limited and is not guaranteed.

Indicate # of credits you plan to take:Fall ______Spring______

  1. Preferred Area(s) of Interest (Check maximum of 3):

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Addictions/substance abuse

Child welfare

Mental Health

Community organization

Criminal justice/corrections

Domestic violence/sexual abuse

Employee assistance programs

Health care/medical

Homelessness

Hospice

International/refugees

Legislative/political

School social work

Services for the elderly

Services to people with disabilities

Special education: LD/ED

Veterans/military

Other ______

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  1. If you have a documented disability for which you would like to request reasonable accommodations in your field agency, you are encouraged to contact the CUA Office of Disability Support Services (DSS), (202-319-5211).Through DSS, you will be asked to sign a release of information so that the Office of Field Education can collaborate with DSS to ensure you have proper accommodations.
  2. Please provide contact information for an individual whom we may call in the event of an emergency at your internship site. This person would only be contacted in the event of an emergency, e.g. medical emergency or accident.

Name: ______

Relationship: ______Phone: (cell): ______

Phone: (work): ______(home): ______

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