Fillable M MSW Practicum Inventory-rev07-18-fillable

Fill Online, Printable, Fillable, Blank M MSW Practicum Inventory-rev07-18-fillable 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 Inventory-rev07-18-fillable

On average this form takes 17 minutes to complete

The M MSW Practicum Inventory-rev07-18-fillable form is 5 pages long and contains:

  • 0 signatures
  • 45 check-boxes
  • 48 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 7/2018
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)
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.
Mark if
you
have:
Rate level of nterest:
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.
3
Mark if
you
have:
Rate level of nterest:
Fields of Practice:
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.
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 in mind or other areas of interest that you would like us to consider for your
practicum? If so, please list them.
3. Where are you interested in a practicum placement?
Wichita / Sedgwick County
Hutchinson
Cowley County
Butler County
Other
4
4. Do you understand the hours required for practicum?
(Foundation: 240 hours per semester - example: 15 hours/week x 16 weeks = 240 hours)
(Advanced Generalist: 350 hours per semester - example: 22 hours/week x 16 weeks = 350 hours)
Yes No
5. 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
Insurance
I understand that I may be placed with an agency that requires one or more of the following types of insurance
coverage: (a) professional liability, (b) automobile liability, and/or (c) health/medical. By signing this
application, I hereby acknowledge that, if placed with an agency that requires such coverage, I am
obligated to obtain, at my sole cost and expense, such insurance and maintain the requisite coverage
during the duration of my practicum. I further understand and acknowledge that Wichita State is under
no obligation to provide such insurance coverage on my behalf and indeed does not and will not provide
such insurance coverage on my behalf. I may request a practicum placement with an agency that does not
require some or all of the above insurance requirements. While Wichita State University will make a reasonable
attempt to accommodate this request, I understand and acknowledge that such accommodation is not
guaranteed.
I hereby request to be placed in a practicum that does not require the following (check all that are applicable):
Professional liability insurance in the amount of $1,000,000 in each instance/$3,000,000 in the
aggregate.
Automobile (including liability) insurance
Health/medical insurance (including hospitalization coverage)
NOTE:
The NASW Social Work Student Professional Liability Insurance can be obtained by members of NASW. To
apply for membership online go to https://www.socialworkers.org/membership/membership-types/students.
If you are a member of NASW, Student Liability Insurance application forms can be found at
http://www.naswassurance.org.
5
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.
Practicum Manual Acknowledgement
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.
Disabilities / Modifications
Wichita State University is committed to providing equal access to employment, educational programs, and
activities for students with disabilities. The University recognizes that students with disabilities may need
accommodations to have equally effective opportunities to participate in or benefit from University educational
program, services and activities and will make reasonable modifications to the environment, policy and practice
and/or provide auxiliary aids and services when the Office of Disability Services determines such modifications
are needed for equal access.
Reasonable accommodation will be considered and may be made to qualified students who disclose a disability,
so long as such accommodation does not significantly alter the essential requirements of the curriculum and the
training program, or significantly affect the safety of others.
I also understand, and acknowledge that it is my responsibility to notify Wichita State University if I am in need
of an accommodation. I further understand and acknowledge that it is my responsibility to notify Wichita State
University if there is any reason I cannot meet the expectations of the Social Work Program, with or without
reasonable accommodations.
I certify that the information on this application form is accurate and complete.
Signature of applicant (type name if submitting electronically) Date
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 Inventory-rev07-18-fillable

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 17 February 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document