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Enhanced Placement Certification Agreement -
SAMPLE
Between ABC School of Social Work,
XYZ MH/MR Center, and Philadelphia Connections
ABC School of Social Work (hereafter referred to as ABC), the XYZ Community
Mental Health and Mental Retardation Center (hereafter referred to as XYZ), and
Philadelphia Connections (hereafter referred to as Connections) agree to fulfill
the following conditions of agreement to the best of their ability as listed
under each organization’s list of responsibilities. No part of these conditions
may be altered without the agreement of Connections as well as the concurrence
of all three parties when Connections determines that unanimity is appropriate.
Background:
Connections is an organization funded by the Philadelphia Behavioral Health
System (BHS) which provides support for collaborative efforts between schools of
social work and BHS care providers. The collaborative efforts described in this
agreement are aimed at providing:
· Enhanced placement experiences to ABC social work students who are in a field
placement at XYZ
· Recognition through EP Certification status to the XYZ MH/MR Center for its
efforts to serve as an outstanding placement site for MSW students and an
enhanced educational environment for staff and students
· Free-of-charge presentations on BHS family/consumer issues for agency staff
and school students and faculty
· Free-of-charge presentations on clinical supervision issues to XYZ staff who
supervise students
· The opportunity for both the school and provider agency to obtain additional
funding for other collaborative efforts that benefit agency staff and school
faculty and students.
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AGREEMENT
ABC School of Social Work will:
A. Designate one liaison person and a back-up to work with Connections staff;
B. Provide Connections with contact information on all EP students prior to the
beginning of the first semester of the placement if possible;
C. Require the participation of the EP student in a BHS Orientation at the
beginning of the field placement, and subsequent EP presentations (unless
special circumstances arise and are discussed by the student and/or ABC liaison
with Connections staff prior to the events). The ABC placement liaison will
monitor and assure participation in EP activities in the same manner as any
other placement obligation of the student.
D. Make arrangements (with Connections assistance) for one family/consumer
presentation at the ABC during the period of [9/30/03 to 5/31/04.] Arrangements
should be completed by [1/31/04] for the presentation. ABC will choose the time,
place and audience; presentation to an appropriate class in a location where
other students/faculty might attend is suggested.
E. Ensure the participation of EP student(s) and EP ABC personnel in the ongoing
evaluation of the impact of the EP program and participants’ level of
satisfaction.
F. Inform Connections staff in advance, when possible, whenever there is a
change in EP-related ABC personnel, and provide contact information concerning
the new personnel.
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XYZ MH/MR Center will:
A. Designate one liaison person and a back-up to work with Connections staff;
B. Provide Connections with contact information on EP student field supervisors
prior to the beginning of the first semester of the placement when possible;
C. Support and require the participation of the EP student in a BHS Orientation
at the beginning of the field placement, and subsequent EP presentations (unless
special circumstances arise and are discussed by the student or the XYZ liaison
with Connections staff prior to the events). XYZ will be expected to provide
time within the field placement hours to attend the EP initial orientation and
at least two days of subsequent EP presentations unless special circumstances
arise and are discussed with Connections staff in advance. The XYZ field
placement supervisor will be expected to monitor and assure participation in EP
activities in the same manner as any other placement obligations of the student.
D. Make arrangements (with Connections assistance) for one family/consumer
presentation at XYZ during the period of [9/30/03 to 5/31/04.] Arrangements
should be completed by [1/31/04] for the second presentation. XYZ will choose
the time, place and audience; presentation to staff in a location where other
provider staff might attend is suggested.
E. Ensure the participation of EP student(s) and EP-related provider staff in
the ongoing evaluation of the impact of the EP program and participants’ level
of satisfaction.
F. Provide time (when necessary) for EP field placement supervisors to attend
three to four Connections-arranged and sponsored presentations on clinical
supervision issues during the course of the field placement.
G. Inform Connections staff in advance, when possible, whenever there is a
change in EP-related XYZ staff such as the field supervisor, and provide contact
information concerning the new staff within two weeks of the new staff member’s
start date.
H. Attest to adherence to appropriate BHS regulations. By signing this, the
provider attests that this agency adheres to the appropriate Community
Behavioral Health (CBH) regulations regarding graduate students. These
regulations are contained in Provider Bulletin 00-23 of September 2000
("Receiving Reimbursement for Graduate Students in Field Placements and Assuring
Standards of Student Supervision"--Pages 6.5, 6.6, 6.7, 6.8, 6.9, 6.10 and
6.11), and can be found on the CBH web site at: http://www.phila-bhs.org/bulletins.html
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Connections will:
A. Designate a staff member to work with ABC and XYZ liaison or backup, and
provide full contact information on the Connections staff member;
B. Provide comprehensive information to the EP students and their field
supervisor(s) (in person, when possible) concerning Connections, the EP program,
and what participation in the program will involve prior to the beginning of the
first semester of the placement. Connections staff will continue to provide this
EP “orientation” to any new ABC or XYZ staff joining the EP project as long as
Connections is made aware of changes in staffing;
C. Schedule and manage the BHS Orientation at the beginning of the field
placement, including notifying all those involved in the EP what the schedule
will be, what speakers are presenting and their topics, and presentation
outlines and handouts when available. Connections will follow this same
procedure with all subsequent EP presentations.
D. Work with XYZ and ABC to arrange the family/consumer presentation each will
host once during the time period specified above. This will include arranging
for speakers provided by the Family Training and Advocacy Center for Serious
Mental Illness (FTAC), reimbursing the presenters, taking responsibility for
extra-agency publicity if the presentation is open to the public or other EP
schools or providers, conducting audience evaluation of the presentation
afterwards, and providing other administrative assistance as needed.
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E. Design and conduct ongoing evaluation of the impact of the EP program and
participants’ level of satisfaction. Results of this evaluation will be
available to all EP participants.
F. Provide three to four Connections-arranged and sponsored presentations on
clinical supervision issues for field supervisors during the course of the field
placement. For presentations which take place during work hours, Connections
will reimburse XYZ for the supervisors’ time at the rate of $30 an hour if
desired. These funds are not part of the EP budget;
G. Provide funds for proposals which are approved and agreed upon by ABC, XYZ,
and Connections for training/educational purposes related to the BHS consumer
population for staff, faculty, and students at ABC and XYZ.
H. Provide the name of the XYZ MH/MR agency to area schools of social work and
to appropriate BHS oversight agencies (including Community Behavioral Health) as
an EP Certified Agency and provider of an enhanced educational environment for
students and staff.
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EP Students placed at XYZ for the 2003-2004 School Year:
Student name 1
Student name 2
Etc.
Agreed to on this date of _____________________________by:
Max Molinaro (Connections) _____________________________
Provider Representative (ABC)____________________________
School Representative (XYZ) _____________________________
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