Fillable B BSW Practicum Inventory Rev 11-17 - Fillable

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B BSW Practicum Inventory Rev 11-17 - Fillable

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Revised 11/2017
BSW
PRACTICUM INVENTORY
To Determine Practicum Interest and Availability
The information you provide below will be used in selecting your field learning experience
(practicum). The following documents are necessary to complete the practicum application. This
application should be completed prior to your interview with a director of the field practicum
program.
Completed Practicum Inventory
Resume
Narrative Statement of Explanation (if prior convictions of felonies/misdemeanors,
diversions, or pending charges)
Signed Liability Insurance Notification Form
Signed Practicum Manual Acknowledgement Form
If you are requesting to complete a practicum with your current employer, then you are required to
include:
Employment Situated Practicum Exceptions Form
I have been admitted to the University Certificate Program in Social Work and Addictions, so I
will need an addictions practicum.
I have been admitted to the University Certificate Program in Child Welfare, so I will need an
child welfare practicum.
Date
MyWSU Id:
Name
Last First Middle Other
Address
Street / P.O. Box
City State Zip
Phone
Home Cell Work
Email(s)
@shockers.wichita.edu
* Reminder: You are responsible for all email communications to your WSU account!
2
FIELD INVENTORY: The goals of this interest inventory are to determine student areas of interest. Listed
below are a number of fields of interest and activities related to the social work field. On a scale of 1-10
(1 = very little interest; 10 = strong interest), please rate your interest level in each field of practice.
if you
Rate level of
interest:
Paid
Experience
Volunteer
Experience
Fields of Practice:
1. Addictions
Working with individuals, groups and families who experience issues related to
addiction (drug, alcohol, sex, hoarding and/or gambling).
2. Children Services
Services to children in need of protection and care; investigations of abuse and neglect;
adoption and foster-home evaluations; services to abused, neglected and victims of
incest; and assistance to children with behavioral or learning problems, to improve
their functioning.
3. Community Services
Assisting in planning, advocacy, evaluation, and change in social service delivery
systems; and outreach to advise the community of available resources.
4. Disability Services
Working with children or adults with mental and/or physical disabilities and their
families.
5. Diversity
Address issues of discrimination and/or oppression with vulnerable populations.
6. Emergency and Economic Supports
Assisting clients to obtain shelter and emergency food and to identify and obtain
needed financial, medical, or social services. Disaster relief services. Working with
homeless.
7. Family Services
Assisting parents in understanding the needs of their children; assisting families with
problems in social functioning; providing support therapy for parents who
abuse/neglect their children; family preservation services.
8. Forensic
Services related to corrections, courts, incarceration, probation or parole for youth and
adults.
9. Healthcare
Assisting patients and families affected by illness or injury with their bio-psycho-social
needs in an inpatient, rehab, outpatient, clinic and/or hospice setting.
10. International Social Work
Working with multi-national, trans-national, international, governmental, or NGO’s to
provide traditional social services, disaster relief, human rights or development of
services or services to military families.
11. Mental Health
Assisting the mental health needs of individuals, families, services through employee
assistance programs, or groups.
12. Political Action and Advocacy
Participating and organizing in agency and/or community efforts for political advocacy.
Development of research to and in political advocacy as related to social issues and/or
disenfranchised populations.
3
13. Schools
Collaborating with teachers and parents about school-related problems of children;
assisting children with behavioral and learning problems.
14. Senior Services
Assisting older adults and their families/caregivers with the psychosocial adjustments
to growing old (i.e. financial, loss, housing). Providing services for the abused and/or
neglected.
15. Women’s Services
Providing services to women faced with issues including domestic violence and sexual
assault.
16. Youth Services
Providing services to adolescents living in residential (small-group) homes; to runaway
youth; in detention; counseling regarding unwanted pregnancies; education for
prevention of pregnancy; victims of incest, abuse and neglect; and assisting youthful
law offenders to improve functioning.
1. Of the sixteen areas listed above, which are your “top 3”?
A.
B.
C.
2. Do you have any agencies or organizations in mind that you would like us to consider for your practicum?
If so, please list the agencies or organizations.
3. Where are you interested in a practicum placement?
Wichita / Sedgwick County
Hutchinson
Cowley County
Butler County
Other
4. Do you plan to complete your practicum at your place of employment? If so, an “Exceptions Form” needs
to be completed. It can be found online at http://www.wichita.edu/socialwork/practicumforms
, and must
be included with this application.
Yes No
5. I have an automobile, with liability car insurance, for use in my field practicum if needed:
Yes No I do not drive (please list form of transportation)
if you
Rate level of
interest:
Paid
Experience
Volunteer
Experience
Fields of Practice:
4
6. I have health insurance that includes hospitalization coverage.
Yes No
7. Do you understand that Practicum requires 240 hours per semester
(for example, 15 hours/week x 16 weeks = 240 hrs)
Yes No
8. List hours and times of day you are available for practicum placement:
Day
None
8 am – 5 pm
5 – 9 pm
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
9. Are there any personal, physical or emotional barriers that will make it difficult for you to participate in
practicum?
Yes No
If yes, please explain:
If yes, are you receiving services through WSU Disability Services in which accommodations would be
needed in an agency setting?
Yes No
If yes, please explain:
Background Information
Have you ever been convicted of a felony or misdemeanor as an adult? Yes No
Has any governmental agency ever substantiated allegations made against you for physical, mental or
emotional abuse or neglect, sexual abuse, or exploitation of (1) a child, (2) a resident of an adult care home,
medical care facility, psychiatric hospital or state institution, or (3) an adult?
Yes No
If you answered yes to either of the above, please attach a narrative statement of explanation.
Answering “yes” does not automatically disqualify you for admission to the BSW program. However,
depending on circumstances, it may affect your ability to be placed in a field practicum which is necessary to
complete the BSW program. Please contact the Field Practicum Director if you have any questions.
I understand that prior convictions, diversions or pending charges may affect my ability to be placed in a field
practicum which is necessary to complete the BSW program. This means that while you may be admitted to
the program, you may not be able to complete the degree if there is something in your background that would
prevent you from being placed in a field practicum. Many agencies require background checks. Some criminal
charges may affect your ability to be licensed in the State of Kansas.
I certify that the information on this completed application form is accurate and complete.
Signature of applicant (Type name if submitting electronically.) Date
5
Liability Insurance Notification
I, , certify that I understand I will be required to obtain Student
Liability Insurance. The liability insurance must cover the time I will be in practicum, which is the August -
May school year. I will provide proof of coverage to the WSU Practicum Staff by July 15.
Signature of applicant (Type name if submitting electronically.) Date
NOTE:
The NASW Social Work Student Professional Liability Insurance can be obtained by members of NASW. To apply
for membership on-line go to https://www.socialworkers.org/nasw/join/default.asp
.
If you are a member of NASW, Student Liability Insurance application forms can be found at
http://www.naswassurance.org
.
07/05/2017
6
Practicum Manual Acknowledgement
I, , certify that I have been advised to read the Wichita State University School of
Social Work Field Practicum Manual, located at
http://webs.wichita.edu/?u=SOCIALWORK&p=/Practicum/Practicum_Manual/.
I agree to follow the expectations outlined in that manual throughout the course of my field placement
experience.
Student Signature
Date
10/2011
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Completed 16 February 2020

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