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Section 4.03.03: Student Agreement to Participate in Field Placement Release of Information Form

I, __________________, am a student in the School of Social Work at the University of Michigan. I understand and agree, in accordance with the curriculum requirements outlined in the School of Social Work Student Guide (ssw.umich.edu/msw-student-guide/), that in order to complete the social work program in which I am enrolled, I will be required to complete a field placement with an agency, organization or university affiliated field placement. The Office of Field Education (OFE) has over 500 placement slots that provide quality social work experiences for students. These sites range from grass roots organizations to large, multi-program, multi-disciplinary facilities. Students will have placement opportunities that match their method and area of concentration, along with their minor, if they have chosen this option.

I understand that if I do not have transportation or access to transportation that my field placement options will be quite limited. OFE has “local” field locations as far west as Grand Rapids, as far north as Saginaw, as far east as Detroit and as far south as Toledo and I am aware that there are limited public transportation options within and between Washtenaw and other counties. I also understand that a majority of field placements are going to be a minimum of a 30–40 minute commute one-way and some longer.
I understand that I am responsible for my own transportation and that the University of Michigan and/or the School of Social Work is not responsible for my travel to and from my field placement.

I understand that as a condition of my field placement, I am required at my own expense, to consent to, complete and pass any or all fieldwork site required background checks such as criminal, child-elder abuse, driving record, sex offender, substance use testing, etc. I understand that my background check results may influence my placement options and my future ability to become licensed.

I understand and will accept a field placement that may not be with the population or the fieldwork site I have chosen. For example, if I am an interpersonal practice student, I also understand that “clinical” placements are defined in a multitude of ways and that very few fieldwork sites offer training in learning how to do long-term “therapy.” The low number of these placement options is due to insurance reimbursement regulations and the fact that this type of work is not usually within the mission/scope of practice of a majority of social work agencies.

I understand and agree that while I am in field placement, I am NOT covered by workman’s compensation for any accident/injury that may occur during my time at the fieldwork site doing field placement related business. I understand that I, or my medical insurance plan, are responsible for all expenses incurred while I am working in my field placement and that the University of Michigan and the University of Michigan School of Social Work assume no responsibility or liability for any injury I might sustain. Therefore, I specifically release the University of Michigan, its schools, departments, agencies, officers, directors, and employees from any such responsibility or liability.

Special Accommodations
Any student seeking accommodations is encouraged to contact the Office of Services for Students with Disabilities at the beginning of the term (https://ssd.umich.edu/). This office assists students in negotiating disability-related barriers to the pursuit of their education.

Release of Information
As a part of the field placement assignment process, the OFE will need to share student placement materials and other relevant information with potential fieldwork sites and Field Instructors. This includes discussions with the prospective Field Instructor, sending a copy of the student’s goal statement, résumé, student agreement, and prior placement evaluations if applicable/requested. These materials enhance the matching process which generally benefits the student and the Field Instructor.

Without a written release, the Office of Field Education is unable to provide the fieldwork site with the information required to make a determination regarding the student’s field placement.

This release also covers all collaboration between the fieldwork site and the Office of Field Education/School of Social Work after the placement has been confirmed.

I hereby give my permission to the Office of Field Education, School of Social Work at the University of Michigan, to release any and all information included in my application for field placement to potential fieldwork sites and Field Instructors for the purposes of arranging field placement(s). This release extends to several fieldwork sites when necessary for confirmation of a mutually agreeable placement site. This release does not apply to my application materials to the School of Social Work, personal references, or transcripts. My signature on this agreement indicates that I have read and understand this agreement and represents that I meet and agree to all criteria listed above.

I have read this Participation Agreement and I understand and agree with it.

Professional Liability Insurance
The University of Michigan self-insures its Medical Professional Liability Insurance coverage. This program includes coverage for sponsored activities of the University and its departments (including the School of Social Work). Coverage also applies to all enrolled students while acting within the scope of University sponsored activities including course required activity to complete their degrees. The University’s self-insurance program is permanently funded, non-cancelable, and provides limits in excess of $1,000,000 each occurrence and $3,000,000 annual aggregate. More information on Medical Professional Liability Insurance can be found here: http://www.finance.umich.edu/risk-management/medical-professional-liabil.... A letter documenting this coverage is available from the OFE office manager.
 

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