Indiana University School of Social Work



Indiana University School of Social WorkS651/652 MSW PRACTICUM II - III(9 credits)Practicum Application FORM Date Submitted:Student I.D. #:Last Name (type below)First Name (type below)Email: (type below) IU Account OnlyStreet Address (type below)City, State (type below)Zip Code (type below)Home Phone (type below)Work Phone (type below)Cell Phone (type below)ConcentrationChild Welfare Scholars Non- scholarsHealthLeadershipMental HealthSchoolsPlacement Year ______/____________Month and year you plan on startingConcentration PracticumPlacement Options – 640 HOURSTwo Semester 16 hrs/16 weeks – 24 hrs/16weeks)Two semester 20 hours/32 weeksTwo semester Extended 16 hrs/40 weeks One Semester Block (40 hrs/16 weeks)PLAN on:Employment Based Practicum/Petition to followInternational Place of Employment:Date Started:Prior Education UniversityDegreeYearUniversityDegreeYearPRIOR Social Work PlacementsOrganizationField Instructor/SupervisorBSW Junior Year(if applicable)BSW Senior Year(if applicable)MSW S555 Practicum ____________________________________________ _________________________PRIOR Non-Social Work PlacementsAcademic DepartmentOrganizationOn-Site InstructorProfessional Career Goals:What are your professional career goals immediately post-graduation and 5 years post-graduation?Educational Goals:Identify at least three (3) educational goals that you want to reach in your advanced year practicum. Please identify the populations and target social issues you still need more opportunities to practice with.Non English ProficiencyDo you speak Spanish?If yes, what is your proficiency level? YesNoDo you speak another language?If yes, please note _____________________________YesNoTransportationIs a car available?YesNoAre car and driver insured?YesNoSpecial ObligationsAre there any obligations that should be considered in planning a placement (e.g. child care, employment, scheduling, etc.)?YesNoIf yes, please explain:651/652 Background History AddendumPlease answer the following questions. If you answer “Yes”, please provide explanation including, dates, charges, and outcomes.Have you ever been arrested or convicted of a crime that has not been expunged by a court?If yes, please give full particulars in order for this application to be considered.Have you ever been required by any licensing board or professional ethics body to surrender their license or been found guilty of a violation of ethics codes, professional misconduct, unprofessional conduct, incompetence or negligence in any state or country?If yes, please give full particulars, and copies of charges, correspondence and any findings in order for this application to be considered.Are there any complaints, charges or investigations pending against you by any licensing board or professional ethics body for violation of ethics codes, professional misconduct, unprofessional conduct, incompetence or negligence in any state or country?If yes, please give full particulars, and copies of charges, correspondence and any findings in order for this application to be considered.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?Has any professional liability claim or suit ever been made against you, your predecessors in business or against any past or present partner(s)?Are there any circumstances of which any professional liability claim or suit is being made against you?Have you engaged in or ever been engaged in any sexual misconduct with any current or former student or 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.) Yes NoYes NoYes NoYes NoYes No Yes NoYes NoActivity LimitationsDo you have physical or other condition that will limit your activity or which should be considered in planning a placement?YesNoIf yes, please explain:Requests for AdaptationStudents in need of some reasonable modification of the instructional context are to meet with the Coordinator to discuss the needed modification. If the modification requires the assistance of personnel, equipment, or materials that are beyond those readily provided by the instructor, then the student is to be referred to Adaptive Educational Services (AES).Upon referral to Adaptive Educational Services, the student must:Sign a request for services based on the presence of a disability.Provide appropriate diagnostic information that establishes that she/he is a qualified individual with a disability; andRequest in writing the reasonable modification(s) sought to accommodate the qualifying disability.AES arranges (in consultation with instructional staff) to provide appropriate modifications.Do you need any Adaptive Services on site during your placement?YesNoIf yes, please explain:OtherIs there anything else you want the School to consider in arranging your field placement?Section IV 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 you want us to START with. If not available we will move on to other locations.Zone 1Zone 2Zone 3Zone 4 Gary Michigan City Rensselaer Valparaiso Goshen Plymouth Rochester South Bend Warsaw Angola Bluffton Columbia City Decatur Fort Wayne Huntington Crawfordsville Frankfort Lafayette LebanonZone 5Zone 6Zone 7Zone 8 Kokomo Logansport Marion Wabash Anderson Greenfield Muncie New Castle Richmond Greencastle Terre Haute IndianapolisZone 9Zone 10Zone 11Zone 12 Brookville Connersville Greensburg Rushville Shelbyville Bloomington Columbus Martinsville Mooresville Seymour Evansville Jasper Tell City Vincennes Lawrenceburg Madison New Albany North Vernon ScottsburgInstructions for SubmissionType 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.On a separate document, prepare an educational resume using the format provided at the end of this document.Submit an electronic copy of this Practicum Application Form and your Educational Resume AS SEPARATE DOCUMENTS by the due date. YOU MUST USE your university email address when sending these documents. Failure to submit the Practicum Application Form and Educational Resume by the due date, from an university student address will result in your placement process being delayed, possibly for one or more semesters.STATEMENT OF UNDERSTANDINGI understand the following:Any information that is deemed important to the placement will be shared with the field instructor including but not limited to: transcripts, academic plan, advising notes, other academic related correspondence and materials, field evaluations.Agencies may require a criminal history check and this may be at my expense.Agencies may require health screenings and this may be at my expense.Declining an agency request for a criminal check or health screening is likely to limit my placement options.Any conviction of sexual offenses against children will deem me ineligible for continuation in or completion of the field program.I am responsible for all materials in the MSW HandbookI am aware I must attend the required field orientation prior to beginning practicum.Student NameDateSocial Work Student Field Placement Code of ConductSocial Work students are expected to adhere to the standards and ethics of the profession that is, the National Association of Social Workers (NASW) Code of Ethics and the Standard of Council on Social Work Education (CSWE). Prior to your placement you are asked to review the entire NASW Code of Ethics. What follows are some of the major standards for practice in the field:Commitment to Clients (1.01)Social workers primary responsibility is to promote the well-being of clientsSelf Determination (1.02)Social workers respect and promote the right of clients to self-determination and assist clients in their efforts to identify and clarify their goals.Conflicts of Interest (1.06)(a)Social workers should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment.(b)Social workers should not take unfair advantage of any professional relationship.(c)Social workers should not engage in dual or multiple relationships with clients or former clients, in which there is a risk of exploitation or potential harm to the client.Privacy and Confidentiality (1.07)Social workers should protect the confidentiality of all information obtained in the course of professional services except for compelling professional reasons.Sexual Relationships (1.09)Social workers under no circumstances engage in sexual activities or sexual contact with current clients, whether such contact is consensual or forced.Physical Contact (1.10)Social workers should not engage in physical contact with clients when there is a possibility of psychological harm to the client as a result of the contact (such as cradling or caressing clients).Derogatory Language (1.12)Social workers should not use derogatory language in their written or verbal communications to or about clients. Social workers should use accurate and respectful language in all communications to and about the clients.Dishonesty, Fraud, and Deception (4.04)Social workers should not participate in, condone, or be associated with dishonesty, fraud or deception. Note: If at anytime during your field placement you find yourself in a situation in which you have questions/concerns about a potential ethical dilemma, please contact your field instructor, faculty field liaison, or field coordinator.I understand as a field practicum student that I am expected to adhere to the values, ethics, and standards of the profession.Student NameDateIndiana University School of Social WorkS651/652 Practicum II - IIIRESUME OUTLINE AND GUIDELINESThis is an outline to be used by MSW Concentration practicum students in preparing information to be shared with MSW Concentration practicum field instructors. Your resume should be professional in appearance.GUIDELINES FOR USE OF OUTLINE1.Please use the topics below as you prepare your professional educational resume. This resume should be 2-3 pages in length and easy to read.2. Please keep a copy for your own record.EDUCATIONAL RESUME OUTLINENamePresent address (include zip code)Present telephone (include area code)Beeper/Pager/Cell Phone numbers, if applicableIUPUI E-mail AddressUndergraduate 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 concentrationPrevious 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 goalsWork Commitment after graduation (If yes, where and type of commitment)Professional organization membershipAdditional information (include physical or other conditions that would limit your activities which should be considered by a field instructor; also any other information you deem relevant)Availability of car* * * * * * * * * * * ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download