Indiana University School of Social Work S651/652 MSW ...

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The School of Social Work cannot guarantee placement in a practicum. If unable to ... Secretary at [email protected] by the due date. Failure to submit the ...
Indiana University School of Social Work S651/652 MSW PRACTICUM II/III PRACTICUM APPLICATION Contact Information Name Street Address City, State, Zip Home Phone Cell Phone IU Email Address Student ID

Anticipated Concentration o Child Welfare o Health o Leadership o Mental Health o Schools

Intended Start Date Semester/Year o Summer o Fall o Spring Placement Options – 640 HOURS o Two Semester Concurrent (16 hrs/16 weeks – 24 hrs/16weeks) o 20 hours/32 weeks o Extended 16 hrs/40 weeks o Block (40 a week for 16 weeks; not applicable to schools concentration)

Program (check all that apply) o Advanced Standing / Accelerated o Advanced Standing o Full Time o Part Time Day o Part Time Evening o Part Time Saturday o Child Welfare Scholars

Practicum Planning Consideration Please check and complete any necessary documentation for all that apply: □

Request for Employment Based Practicum (If checked, please attach Petition for Employment-Based Practicum)



Registration with Adaptive Services (If checked, please indicate accommodation needs for practicum and if you need this consideration in placement planning



Language Proficiency in language other than English (please indicate language)

Office Use Only Review Date _/ Coordinator o Weiler o Satre o Omorayo o Dennis o Bell

_/

□ Employment considerations: If you plan to also maintain employment while in your practicum placement, please indicate the number of hours you plan to work for employment □ Background check considerations: Please note any background considerations that could impact your placement (criminal history, CPS history, pending charges, DUI, etc.). If you have legal or criminal charges or history, please describe below: o Misdemeanor: o o o o

Felony: CPS: Pending: Other:

□ Other considerations for practicum planning: Describe any other circumstances that should be considered in the practicum planning process (e.g., availability of transportation).

Previous Social Work Placements Agency: Primary Field of Practice Primary Population Served Previous Non-Social Work Placements Agency: Primary Field of Practice Primary Population Served

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Geographical Preferences Every effort is made to place students within reasonable distance of home; however, students must be prepared to consider relocating or commuting for a field placement during the concentration year of the MSW program. Please indicate zone and city and/or cities in which you want your placement. Zone 1 Zone 2 Zone 3 Zone 4 Gary Goshen Angola Crawfordsville Michigan City La Porte Bluffton Frankfort Rensselaer Mishawaka Columbia City Lafayette Plymouth Decatur Lebanon Valparaiso Rochester Fort Wayne West Lafayette South Bend Huntington Warsaw Zone 5 Zone 6 Zone 7 Zone 8 Carmel Anderson Brownsburg Indianapolis Fishers Greenfield Greencastle Downtown Kokomo Hartford City Linton Northside Logansport Muncie Southside Terre Haute Marion New Castle Eastside Noblesville Portland Westside Peru Richmond Tipton Wabash Zone 10 Zone 11 Zone 12 Zone 9 Brookville Bedford Evansville Lawrenceburg Connersville Bloomington Jasper Madison Greensburg Columbus Tell City New Albany Rushville Greenwood North Vernon Vincennes Martinsville Shelbyville Scottsburg Mooresville Seymour

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Background History Addendum

Student Name:

*Please note that most agencies that participate in the practicum program require criminal background checks at the applicant’s expense. Failure to disclose and accurately describe the details of an arrest or conviction that has not been expunged by a court could prevent you from being placed at an agency. The School of Social Work cannot guarantee placement in a practicum. If unable to identify an agency willing to accept a student based off of his or her criminal history, the student will not be able to graduate. a. Have you ever been arrested or convicted of a crime that has not been expunged by a court? Please note that expungement and dismissal are distinct and all offenses that have been dismissed in your favor must be disclosed.

Yes

No

Yes

No

Yes

No

Yes

No

d. Have you ever had any insurance company or Lloyd’s decline, cancel, refuse to renew or accept only on special terms any professional liability insurance? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

Yes

No

e. Has any professional liability claim or suit ever been made against you, your predecessors in business or against any past or present partner(s)? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

Yes

No

f.

Yes

No

If yes, please provide a detailed explanation of the incident(s), including the location(s) and date(s) of the charge(s) or conviction(s); your status at the time of release; and the court disposition. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ b. Have you ever been on formal or informal probation? If yes, please provide full details of the program and the final disposition. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ c. Have you ever entered into a diversion program? If yes, please provide full details of the program and the final disposition. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

Are there any circumstances of which any professional liability claim or suit is being made against you? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

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g. Have you engaged in or ever been engaged in any sexual misconduct with any current or former clients/patients or any current or former client’s/patient’s spouse or any person with a direct relationship to the client/patient or former patient (for example a guardian, blood relative of the patient or spouse or any person sharing the patient’s domicile)? (Sexual misconduct means any actual or alleged erotic physical contact or attempt thereat or proposal thereof.) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Please be advised that you will have a continuing obligation to maintain the accuracy of these statements throughout the admissions cycle. If you are offered admission, your obligation will continue after your admission and during your enrollment as a student of our school.

Agreement and Signature By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that the field instruction coordinator and/or social work faculty members will share general information on my employment history, volunteer activities and academic performance in the process of arranging or supervising a field placement. I understand that any information that is deemed important to the placement will be shared with the field facilitator/instructor. I understand that the field instructor for my practicum will have the opportunity to read my academic file, which includes my transcript, academic plan, advising notes, and other academic related correspondence. I am aware that many agencies require criminal checks and health screening (including drug testing, TB and Hepatitis-B tests, etc.) for students to be accepted in placements. Declining an agency request for a criminal check or health screening is likely to limit my placement options. I understand that any conviction of sexual offenses against children will deem me ineligible for continuation or completion of the field practicum courses. I understand that I am expected to demonstrate professional conduct, practice within the scope of social work and the NASW Code of Ethics, in my social work practicum. I understand that a violation of the NASW Code of Ethics may deem me ineligible for continuation or completion of the field practicum courses. I understand that demonstrating behavior that is disruptive, inappropriate, and unprofessional may deem me ineligible for continuation or completion of the field practica courses.

Name (printed) Signature Date

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Instructions for Submission 1. Type your name in both signature boxes asking for your name on pages. By doing so, you are stating that you understand the statements below and will adhere to the Social Work Code of Ethics identified on page. 2. On a separate document, prepare an educational resume using the format provided at the end of this document. 3. Submit an electronic copy of this Preference Form and your Educational Resume to Dee Barnes, MSW Field Secretary at [email protected] by the due date. Failure to submit the Preference Form and Educational Resume by the due date will result in your placement process being delayed, possibly for one or more semesters. Agreement and Signature By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that the field instruction coordinator and/or social work faculty members will share general information on my employment history, volunteer activities and academic performance n the process of arranging or supervising a field placement. I understand that any information that is deemed important to the placement will be shared with the field facilitation/instructor. I understand the field instructor for my practicum will have the opportunity to read my academic file, which includes my transcript, academic plan, advising notes, and other academic related correspondence. I am aware that many agencies require criminal checks and health screenings (including drug testing, TB and Hepatitis-B tests, etc.) for students to be accepted in placements. Declining an agency request for a criminal check or health screening is likely to limit my placement options. I understand that any conviction of sexual offenses against children will deem me ineligible for continuation or completion of the field practicum courses. I understand that I am expected to demonstrate professional conduct, practice within the scope of social work and the NASW Code of Ethics, in my social work practicum. I understand that a violation of the NASW Code of Ethics may deem me ineligible for continuation or completion of the field practicum courses. I understand that demonstrating behavior that is disruptive, inappropriate, and unprofessional may deem me ineligible for continuation or completion of the field practica courses. Name (printed) Signature Date

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Indiana University School of Social Work S651/652 MSW Practicum II/III RESUME OUTLINE AND GUIDELINES This is a suggested outline to be used by MSW Concentration practicum students in preparing information to be shared with MSW Concentration practicum field instructors. You may also follow other resume outlines. Overall, your resume should be professional in appearance. GUIDELINES FOR USE OF OUTLINE 1. Please use the topics below to guide you in preparing your professional educational resume. This resume should be 1-3 pages in length and easy to read. 2. Please keep a copy for your own record.

EDUCATIONAL RESUME OUTLINE Name Present address (include zip code) Present telephone (include area code) Cell Phone numbers, if applicable E-mail Address Undergraduate degree [school(s) attended, date(s), major(s)] Other degrees/diplomas (schools, dates, majors) Special training or certificate(s) received (include non-English language skills and proficiency level) MSW method concentration Learning opportunities hoped for in Practicum including 5-7 learning goals Previous Practicum/Internship Experience (If Advanced Standing, give BSW field placement including name and location of agency and brief description of experiences) Employment Experience (include dates, name of organization, brief description of position) Volunteer Experience (include dates, name of organization, brief description of position) Professional career goals Work Commitment after graduation (If yes, where and type of commitment) Professional organization membership * * * * * * * * * * *

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Mary Sample 1223 Forest Glen Avenue Kirkland, Indiana 46203 (317) 555-5555 [email protected] EDUCATION IUPUI, School of Social Work, BSW, May 1996. IU-Kokomo, School of Business, Associate, May 1993 Indiana Business College, Marion, Indiana, Graduated, 1983. Eastbrook High School, Marion, Indiana, Graduated, 1982. MSW CONCENTRATION Families PREVIOUS PRACTICUM EXPERIENCES August – December 1996 Family Relations Division, Tippecanoe County Courts Lafayette, Indiana BSW Senior Field Practicum Co-facilitated Divorcing Parent Workshop. Completed in-take assessment, conducted and observed custody evaluations, and maintained compliance records. January – May, 1996 Northern Hamilton County Substance Abuse Awareness Center Cicero, Indiana BSW Junior Field Practicum Provided case management services (intake interview, service needs assessments, substance abuse assessment, goal setting, referrals) for clients. Co-facilitated support group. EMPLOYMENT HISTORY 1996-Present

1989-1996 (Part-time)

1987-1989

1973-1987 VOLUNTEER EXPERIENCE October 1993 – Present

Family and Children Services, Lafayette, Indiana Case Manager Responsible for case management of seven to ten families referred for abuse/neglect. First National Bank, Pleasantview, Indiana Trainer Responsible for new employee orientation, customer relations, sales, and product knowledge training. First National Bank, Pleasantview Indiana Operations Officer Manager of customer service area; managed nine employees. Held five other part-time and full-time positions within the financial industry.

Clinton County Detention Center. Co-facilitate a weekly substance abuse group.

PROFESSIONAL CAREER GOALS Once completing my MSW Education and working for a year, I plan to acquire my mediation license. I would like to assist divorcing parents in developing workable parenting agreements and specialize in the area of family and children. PROFESSIONAL ORGANIZATIONS Member of the National Association of Social Workers Member/Treasure of the BSW Student Association

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