Appendix I: Field Forms - Overview
FORMS 8/2013 / PERSON RESPONSIBLE1. BSW/MSW FIELD WORK APPLICATION FORM: Student fills this out prior to their meeting with Field Coordinator in preparation for placement in field. Referred To: / Student
2. STudent field agreement with agency: Student brings this form to the agency upon acceptance of practicum placement. Formal record of agreement with field instructor to regarding work hours and contact information. Placed in student file / Student, Field Instructor and Field Coordinator
3. Field Work Agreement in Student’s Place of Employment: Documents how student duties and field instructor for their field practicum differ from employment. / Student, Field Instructor, Employment Supervisor and Field Coordinator.
4. PORTFOLIO OUTLINE: Student maintains a portfolio and has it ready for review at midterm and final. / Student
5. STUDENT DOCUMENT TRACKING FORM - This is a check list with dates. Students are required to keep track of all of their assignments, seminars attended, hours in the field on a summary sheet to be added to their Portfolio. / Student – signed by Field Liaison end of semester
6. WEEKLY SUPERVISORY MEETING AGENDA and TIME AND ACTIVITIES REPORT (one per week) This is a form to help the student keep track of what they are doing each day and the hours they are in the field and the long term goals in the supervision. It is essential that the Field Instructor comment on this form and sign it. / Student and Field Instructor needs to comment and sign (at supervisory meeting)
8. BIOPSYCHOSOCIAL ASSESSMENT MSW 552 or
CASE PRESENTATION OUTLINE MSW 555: Student prepares an assessment or case to present in their seminar. / Student
9. AGENCY PRESENTATION OUTLINE MSW 551 and 554: Student prepares a presentation on their practicum agency. / Student
10. PROCESS RECORDING: TWO PER SEMESTER This is a vital form of evaluation the students’ progress in competency 10 – engagement, assessment, intervention, and evaluation. / Student - Field Instructor comments. Given to Field Liaison
11. CHANGE OF PLACEMENT REQUEST: Students and Field Instructors cannot terminate a placement without providing reasons for the request and an explanation of attempts to address issues. / Completed by student, Field Instructor and Field Liaison
12. BSW/MSW Student Evaluation of Field Agency, Field instructor & liaison: Student should fill this out at the end of every semester. / Student
NMSU School of Social Work Referred To:
BSW/ MSW Field Work Application
Name: ______Date of application: ______
Student Banner ID: ______Academic Advisor: ______
Dates of Placement – August ______to May ______
I am entering the field at the following Program level:
1
(Form 2013)
□ BSW Student Senior Year:
MSW First Year Field Placement:
□ Full-time MSW 1st Year Student Entering Field for the First Time
□ Part-time MSW Student (2nd year) Entering Field for the First Time
MSW Second Year Field Placement:
□ Full-time MSW 2nd Year Student
□ Part-time MSW Student (3rd year)
□ Full-time MSW Advanced Standing
□ Part-time MSW Adv. Standing Student (2nd year)
1
(Form 2013)
Are you receiving a CYFD stipend? ______(yes) ______(no)
Local Address: ______
______
(City) (State) (Zip)
Permanent Address: ______
______
(City) (State) (Zip)
Telephone (____) ______(____)______(____) ______
(Home) (Cell phone) (Work)
E-mail ______
Most recent human service related experience:
1. Agency Name: ______Job title: ______Full time __Part time __
Name of your Supervisor: ______Length of Service: ______
Description of the work you did at this agency: ______
______
2. Agency Name: ______Job title: ______Full time __Part time __
Name of your Supervisor: ______Length of Service: ______
Description of the work you did at this agency: ______
NMSU School of Social Work BSW/ MSW Field Work Application pg 2
You will have two semesters in your field placement. What would you like to learn this year? Be specific. What are the social work skills, roles, and levels of service in which you need more practice experience?
What kind of social work job do you see yourself having in five years?
Place a check mark next to the types of programs you would like consider as placements.
1
(Form 2013)
Children and family services
Mental Health
Medical
Health
Poverty advocacy
Criminal Justice
Schools
Rehabilitation
Public Welfare
Military Services
Substance abuse
Residential treatment
Developmental disability
Elderly
Other
1
(Form 2013)
Feel free to provide contact names and phone numbers if you have a particular interest in an agency. Please note that your choices are given serious consideration, but your field placement setting is determined by agency availability and fit.
1.______
2.______
Means of Transportation:
You will be required to travel to your field site and in the surrounding area. Do you have a means of transportation? Yes______No______
If no, how do you plan to meet these requirements? ______
Other information regarding your field work preferences:
In what geographic area would you prefer your field work to be? (It may be necessary to travel up to 50 miles from your home)
1
(Form 2013)
□ Las Cruces
□ El Paso
□ Alamogordo
□ Albuquerque
□ Grants - Gallup
□ Other ______
1
(Form 2013)
Are you bilingual? □ Yes □ No If yes, list the language(s) you speak in addition to English: ______
Rate your abilities for the additional language(s) you listed using the following criteria.
P = Proficient (exceptionally capable) A = Able D=Developing B=Beginner
______Reading ______Writing ______Speaking _____Translating ______Interpreting
DID you Apply for the Hispanic Child Welfare stipend? ______(yes) ______(no)
OTHER INFORMATION: Do you have any special needs, limitations, and/or recommendations that need to be considered in field agency selection? Please explain. ______
______
Student name______Date ______
NMSU School of Social Work BSW/ MSW Field Work APPLICATION pg3
All students are expected to follow the policies and procedures found in the BSW or MSW Field Education Manual and the NASW Code of Ethics. Therefore prior to beginning a field practicum, all students are required to read and agree to the following:
1. I understand I am responsible for reading and understanding field policies and procedures. Prior to
beginning my field placement, I will review the contents of the BSW or MSW Field Education Manual with
emphasis on:
· Attendance requirements at the agency and field seminar
· Evaluation and Grading
· Standards of Ethical Behavior
· Procedures for addressing placement concerns and termination from the field program
2. I will provide all documentation relevant to field education, completed accurately, to the agency and /or field office on or before their required due dates, starting with this Field Work Application. I understand that I jeopardize my placement opportunities if I fail to do so.
3. I am aware that my prompt response to emails and phone calls from the field office or any member of my Field Education team demonstrates profession standards of regard and responsibility. Demonstration or lack thereof
of this standard will be reflected in my Field Evaluations.
4. I agree to accept supervision and instruction from the agency Field Instructor and (if needed) the Site –Supervisor and the Field Seminar Liaison. I will participate in the development of my social work skills by active involvement in field seminar, field supervision and the Student Evaluation process.
5. Furthermore, I understand that Social Work Field Education is a team effort and my Field Instructor and Liaison will be in communication with each other and with the Field Education Coordinator as needed to discuss and support my progress.
By signing, I agree the above conditions and expectations.
Student signature______Date______
Printed name______
NMSU School of Social Work BSW/ MSW Field Work APPLICATION pg 4
PLEASE SUBMIT A COPY OF YOUR RESUME ALONG WITH THIS APPLICATION.
determinations of eligibility to New Mexico Social Work Licensure
Answering the following questions is required of all applicants for field placement and for determinations of eligibility to New Mexico Social Work Licensure following graduation. Omission of any information may result in our inability to process your application and provide a field placement for you. Provision of this information will not affect your standing in the social work program but it may limit the type of placement setting you will be assigned to. This information will not be shared with a field agency without your express permission. Many agencies have specific background and criminal record check procedures that you must agree to for placement in that agency.
False statements on this form would be evidence of unethical behavior and consequently grounds for termination from the School of Social Work.
1. Have you ever used another name under which records may be filed concerning your application, or your education, training, or experience leading to your application? Yes _____ No _____
2. Criminal record
a. Have you ever been convicted of a felony, DUI/DWI or other criminal offense other than a minor traffic violation, or are there such charges pending against you at this time? Yes: ______No: ______
b. Have you ever had an allegation of either child abuse or adult abuse made against you that was substantiated or is pending against you at this time? Yes _____ No _____
If you answer “Yes” to any of the questions above, you must provide documentation on the nature of the offense/allegation and its disposition and a statement containing proof of rehabilitation if applicable. Please attach this information to your Field Application even if you have submitted the information along with your application to the School of Social Work.
Convictions and pending convictions may limit opportunities for field education, professional licensing and future employment.
3. Have you ever been denied a license or permission to practice Social Work or permission to take an examination to practice Social Work in any state, country, or territory? Yes __ No __ (If yes, please attach a complete and comprehensive explanation)?
4. Has any disciplinary action ever been taken regarding your practice or Social Work or any license you hold or have held to practice Social Work? Disciplinary actions include, but are not limited to, suspension, probation, practice limitations, reprimand, letter of admonition, censure and any allegations currently pending? Yes __ No __ (If yes, please attach a complete and comprehensive explanation).
5. Have you ever voluntarily surrendered a license to practice Social Work in any other state or territory? Yes __ No __ (If yes, please attach a complete and comprehensive explanation).
______
(Student’s Signature) (Date)
Student Field Agreement with Agency
New Mexico State University School of Social Work
If student is seeking to complete the field practicum in his/her place of employment, please use separate form entitled NMSU School of Social Work Field Work Agreement in Student’s Place of Employment.Additional paperwork must be completed and approval granted before the first day of the practicum semester.
Student Information (check one)
BSW First year MSW Second Year or Advanced Standing MSW
Student Name: Interview with Agency Date:
Student Home Phone: Cell Phone: Other Phone:
Student Address:
City: State: Zip Code:
NMSU E-Mail:
Field Instructor Information
BSW or MSW Licensed Agency Field Instructor should complete this portion
Agency Name:
Component(s) of Agency Student placed in (if relevant)
Agency Address: City: Zip:
Field Instructor: Position:
Phone Number: E-mail Address:
Credentials/degrees: LBSW LMSW LISW License #
Agency Based Field Supervisor Information
(If daily supervision will be provided by someone other than Licensed Agency Field Instructor)
Agency Based Field Supervisor:: Position:
Phone Number: E-mail Address:
Credentials/degrees:
NMSU Social Work Students are required to demonstrate competency in ten areas of knowledge necessary to professional Social Work during the field placement. This is done through mastery of practice behaviors related to each Competency below.
1. Practice professional behavior (Demonstrate professional demeanor in behavior, appearance, and communication.)
2. Learn and apply social work ethical principles to guide professional practice
3. Apply critical thinking to inform and communicate professional judgments.
4. Engage with diverse clients in the practice setting
5. Engage in practices that advance social and economic justice
6. Engage in research-informed practice and practice-informed research.
7. Knowledge of human behavior and the social environment
8. Identify relevant policy in practice to advance social and economic well-being and to deliver effective social work services.
9. Identify the process needed to respond to contexts that shape practice
10. Learn to engage, assess, intervene, and evaluate with individuals, families, groups, organizations, and communities.
Any special conditions for this internship: Click here to enter text.
STUDENT’S WEEKLY SCHEDULE IN FIELD - PROPOSEDDay / Field Experience hours
(15 average 1st year field and 17 average 2nd year field hours per week - minimum) including 1 hour of weekly field seminar / Hours that you will be in class or field seminar / Work hours Only (Field hours must be separate from work hours)
Monday / to / to
Tuesday / to / to
Wednesday / to / to
Thursday / to / to
Friday / to / to
Saturday / to / to
Sunday / to / to
______
Signatures
After interviewing the above student our agency has agreed to accept the student for a social work field experience placement and provide the students with an opportunity to develop and practice their competencies.
BSW or MSW Licensed Agency Field Instructor Signature: ______Date:______(Attach copy of his/her resume and license)
Agency Based Field Supervisor: ______
Student agrees to accept this placement:
Student’s Signature ______Date: ______
Student’s Phone Number at the Agency: ______
Student’s Internship address if different than field instructor address (include component of agency’s name)
______
Placement must begin the first week of the semester
Placement approved by: ______Date: ______
Field Coordinator or Assistant Field Coordinator
Las Cruces: Please return to the front desk at the School of Social Work:
Attention: Field Team Staff
Albuquerque Students: Please return to Susan Burns, LISW, Field Coordinator