Fillable M MSW Practicum Inventory Rev 11-17 - Fillable APPLICATION FOR FIELD PRACTICUM PLACEMENT

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M MSW Practicum Inventory Rev 11-17 - Fillable APPLICATION FOR FIELD PRACTICUM PLACEMENT

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Revised September 2017
MSW
PRACTICUM INVENTORY
To Determine Practicum Interest and Availability
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 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
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)
6. I have health insurance that includes hospitalization coverage.
Yes No
4
7. 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
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:
I
f 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
H
as 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
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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M MSW Practicum Inventory Rev 11-17 - Fillable APPLICATION FOR FIELD PRACTICUM PLACEMENT

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Completed 16 February 2020

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