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
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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