Fillable M MSW Practicum App Rev 6-15 1 APPLICATION FOR FIELD PRACTICUM PLACEMENT

Fill Online, Printable, Fillable, Blank M MSW Practicum App Rev 6-15 1 APPLICATION FOR FIELD PRACTICUM PLACEMENT Form

Use Fill to complete blank online WICHITA STATE UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

M MSW Practicum App Rev 6-15 1 APPLICATION FOR FIELD PRACTICUM PLACEMENT

On average this form takes 24 minutes to complete

The M MSW Practicum App Rev 6-15 1 APPLICATION FOR FIELD PRACTICUM PLACEMENT form is 9 pages long and contains:

  • 0 signatures
  • 48 check-boxes
  • 74 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Wichita State University

BROWSE WICHITA STATE UNIVERSITY 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
 
Revised June 2015
MSW
PRACTICUM APPLICATION
Check one:
Foundation Practicum (SCWK 720 & 721)
Advanced Generalist Practicum (SCWK 822 & 823)
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 Application Form
Resume
Narrative Statement of Explanation (if prior convictions of felonies/misdemeanors,
diversions, or pending charges
Signed Application Agreement Form
Signed Ethical Agreement Form
Signed Liability Insurance Notification Form
Signed Practicum Manual Acknowledgement Form
Signed Computer Competency Statement Form
If you are requesting to complete a practicum with your current employer, then you are required to
include:
Employment Situated Practicum Exceptions Form
Date
MyWSU Id:
Name
Address
Phone
Email
* 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.
Mark if
you
have:
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
Mark if
you
have:
Rate level of
interest:
Paid
Experience
Volunteer
Experience
Fields of Practice:
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 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)
4
6. Do you understand the hours required for practicum?
(Foundation: 240 hours per semester – example: 15 hours/week x16 weeks = 240 hours)
(Advanced Generalist: 350 hours per semester – example: 22 hours/week x 16 weeks = 350
hours)
Yes No
7. 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
8. 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 MSW program. However,
depending on circumstances, it may affect your ability to be placed in a field practicum which is necessary to
complete the MSW 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 MSW 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
Application Agreement
I, , have read, understand and agree to comply with all
the terms and conditions in this application for practicum.
Yes No
Signature
Date
6
Ethical Agreement
I, , certify that I have read and understand the NASW Code of Ethics
and I will abide by this code of ethics to the best of my ability. I aspire to learn more about social work’s
values, knowledge and practice skills throughout my student and professional years. I will seek
professional growth through interaction with faculty, colleagues and other assigned tasks in the Wichita
State University School of Social Work program. I understand that failure to demonstrate Social Work
Ethics in my field practicum placement may result in my removal from the program.
Student Signature
Date
NOTE: The NASW Code of Ethics can be found on the NASW website at http://www.socialworkers.org/
.
Rev. 10/2011
7
Liability Insurance Notification
I, , certify that it has been recommended to me to obtain Student Liability Insurance.
Student Signature
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
.
02/21/11
8
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
9
Computer Competency Statement
Students admitted to the School of Social Work are expected to demonstrate competency with the
following computer skills:
1. Word Processing (WORD or Word Perfect preferred – not Microsoft Works) with the following
formatting skills:
• Setting font size and type
• Setting margins
• Setting line spacing
• Creating headers and footers
• Inserting tables
• Italicizing
• Inserting page numbers – in a header
• Centering text; right and left justification
2. Sending and receiving email with attachments
3. Accessing the Internet
4. Students are expected to have familiarity with the following:
• Presentation program (PowerPoint)
• Spreadsheet (Excel)
Students not competent with the above computer skills must complete a computer class prior to
entering the Social Work Field Practicum Program.
I have been informed of the expected computer competency for the Social Work program. I understand
that it is my responsibility to demonstrate competency in the stated skills. I understand that my
grades may be significantly affected by poor application of the above computer skills.
Student Signature
Date
10/2011
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

M MSW Practicum App Rev 6-15 1 APPLICATION FOR FIELD PRACTICUM PLACEMENT

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 16 February 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document