Fillable Louisiana State Board of Social Work Examiners - Professional Experience Verification Record

Fill Online, Printable, Fillable, Blank Louisiana State Board of Social Work Examiners - Professional Experience Verification Record Form

Use Fill to complete blank online LOUISIANA STATE BOARD OF SOCIAL WORK EXAMINERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Louisiana State Board of Social Work Examiners - Professional Experience Verification Record

On average this form takes 11 minutes to complete

The Louisiana State Board of Social Work Examiners - Professional Experience Verification Record form is 2 pages long and contains:

  • 1 signature
  • 0 check-boxes
  • 38 other fields

Country of origin: US
File type: PDF

Louisiana State Board of Social Work Examiners

BROWSE LOUISIANA STATE BOARD OF SOCIAL WORK EXAMINERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
LOUISIANA STATE BOARD OF SOCIAL
WORK EXAMINERS
PROFESSIONAL EXPERIENCE VERIFICATION RECORD
This form is used to verify the number of postgraduate hours a LMSW practices social work. It
shall be completed by the Agency Director, Executive Officer, CEO or Director of Personnel. It
shall be completed when a LMSW terminates employment or at the time the LMSW completes
5,760 hours of postgraduate social work practice (whichever comes first).
This is a two-sided form that can be duplicated if necessary. A separate record shall be
submitted by each place of employment. The original form shall be mailed to the board office.
I
, _____________________________________________________________________ ____________________________________________
(Type or print name of agency representative) (Title)
__________________________________________________________________________________ ___________________________________
(Agency) (Telephone Number)
______________________________________________________________________________________________________________________
(Agency Address)
Certify that _________________________________________, LMSW, is/was an employee of the above
agency.
Beginning Date of Employment _______________________
Month/Day/Year
Ending Date of Employment_________________________
Month/Day/Year
___________________________________________________
Signature of Agency Representative*
___________________________________________________
Date
* Must be signed by Agency Director, Executive Officer, CEO or Director of Personnel.
Submit ORIGINAL to:
LOUISIANA STATE BOARD OF SOCIAL WORK EXAMINERS
18550 HIGHLAND ROAD, SUITE B, BATON ROUGE, LOUISIANA 70809
PHONE: 225-756-3470 or In LA: 800-521-1941 FAX: 225-756-3472
Email:socialwork@labswe.org Web site: www.labswe.org
click to sign
signature
click to edit
Record of Hours of Professional Social Work Practice
Social work practice means the professional application of social work values, theories, and
interventions to one or more of the following: enhancing the development, problem-solving,
and coping capacities of people; promoting the effective and humane operations of systems
that provide resources and services to people; linking people with systems that provide them
with resources, services, and opportunities; developing and improving social policy; and
engaging in research related to the professional activities. The practice of social work shall
include but not be limited to clinical social work, planning and community organization, policy
and administration, research, and social work education. Social work practice is guided by
knowledge of human behavior, biopsychosocial development, social systems and resources,
economic and cultural institutions, and their interactions.
PRINT Name of Social Worker & Credential #_________________________________________________
PRINT Agency Name______________________________________________________________________
YEAR:
Agency Official Signature / Printed Name of Official
Number
Hours
Worked
JAN
FEB
MAR
APR
MAY
JUNE
JULY
AUG
SEPT
OCT
NOV
DEC
TOTAL
HOURS
Mail ORIGINAL to:
Louisiana State Board of Social Work Examiners
18550 Highland Road, Suite B
Baton Rouge, LA 70809
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Louisiana State Board of Social Work Examiners - Professional Experience Verification Record

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 24 May 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document