Field Practicum Application

Mississippi State University - - - Social Work Program

FIELD PRACTICUM APPLICATION

APPLICANT CONTACT INFORMATION
Name: / Click here to enter text. /
Address: / Click here to enter text. /
Email: / Click here to enter text.
Phone Number: / Click here to enter text.
EDUCATION
Present College Name: / Click here to enter text. /
Location: / Click here to enter text. /
Major: / Click here to enter text. /
Expected Graduation Date: / Click here to enter a date. /
Honors/Awards: /

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Previous College Name: / Click here to enter text. /
Location: / Click here to enter text. /
Dates of Attendance: / Click here to enter a date. / to / Click here to enter a date. /
Degree/Certificate:
Honors/Awards: /

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High School Name: / Click here to enter text. /
Location: / Click here to enter text. /
Graduation Date: / Click here to enter a date. /
Honors/Awards: /

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Mississippi State University - - - Social Work Program

FIELD PRACTICUM APPLICATION

EMPLOYMENT EXPERIENCE
Name of Agency: / Click here to enter text. /
Address: / Click here to enter text. /
Dates of Employment: / Click here to enter a date. / to / Click here to enter a date. /
Job Title(s) / Click here to enter text. /
Responsibilities: /

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Name of Agency: / Click here to enter text. /
Address: / Click here to enter text. /
Dates of Employment: / Click here to enter a date. / to / Click here to enter a date. /
Job Title(s) / Click here to enter text. /
Responsibilities: /

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Mississippi State University - - - Social Work Program

FIELD PRACTICUM APPLICATION

VOLUNTEER ACTIVITES
Name of Organization: / Click here to enter text. /
Address: / Click here to enter text. /
Dates of Service: / Click here to enter a date. / to / Click here to enter a date. /
Services: /

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Name of Organization: / Click here to enter text. /
Address: / Click here to enter text. /
Dates of Service: / Click here to enter a date. / to / Click here to enter a date. /
Services: /

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Name of Organization: / Click here to enter text. /
Address: / Click here to enter text. /
Dates of Service: / Click here to enter a date. / to / Click here to enter a date. /
Services: /

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Name of Organization: / Click here to enter text. /
Address: / Click here to enter text. /
Dates of Service: / Click here to enter a date. / to / Click here to enter a date. /
Services: /

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PERSONAL ATTRIBUTES
1. / What are your expectations for field practicum instruction? / Click here to enter text.
2. / Describe how you perceive yourself in relation to:
(a) the values of the profession
(b) readiness to enter a social work setting / (a)Click here to enter text.
(b)Click here to enter text. /
3. / Describe your strengths as a social work student: / Click here to enter text.
4. / Discuss your needs for development and improvement in the practicum setting: / Click here to enter text.
5. / Discuss your plans after graduation: / Click here to enter text.

Mississippi State University - - - Social Work Program

FIELD PRACTICUM APPLICATION

OTHER PERTINENT INFORMATION
Date of Birth:Click here to enter a date. / Driver’s License #:Click here to enter text.
State:Click here to enter text.
Expiration Date:Click here to enter a date.
Do you accept student blanket liability coverage: ☐Yes ☐No / Verify choice by
initialing here:
Please indicate any special needs you have of which your Field Instructor needs to be aware:
Click here to enter text.
What is the total number of hours you have completed? / Choose an item.Hours
What is your cumulative grade point average? / Click here to enter text.GPA
What is your cumulative grade point average in social work courses? / Click here to enter text.GPA
Have you reviewed and signed your senior checksheet? / ☐Yes ☐No
If yes, when: Click here to enter a date.
CURRICULUM
Focus Area / Course / Title / Hours / Grade
Social Work (Pre-Field) / SW 2303 / Social Welfare Policy I / 3 / Choose an item. /
SW 2313 / Introduction to Social Work/Social Welfare / 3 / Choose an item. /
SW 2323 / Social Welfare Policy II / 3 / Choose an item. /
SW 3003 / Populations at Risk / 3 / Choose an item. /
SW 3013 / Human Behavior in the Social Environment I / 3 / Choose an item. /
SW 3023 / Human Behavior in the Social Environment II / 3 / Choose an item. /
SW3213 / Social Work Research / 3 / Choose an item. /
SW 3513 / Social Work Practice I / 3 / Choose an item. /
SW 3523 / Social Work Practice II / 3 / Choose an item. /
SW 3533 / Social Work with Communities and Organizations / 3 / Choose an item. /
SW 4613 / Child Welfare Services / 3 / Choose an item. /
Social Work Elective: Click here to enter text. / 3 / Choose an item. /
SW 4713 / Senior Seminar / 3 / Choose an item. /
Math / College Algebra / 3 / Choose an item. /
Statistics or approved substitute: Click here to enter text. / 3 / Choose an item. /
CURRICULUM CONTINUED
Focus Area / Course / Title / Hours / Grade
ScienceS / Anatomy & Physiology or approved substitute: Click here to enter text. / Choose an item. / Choose an item. /
Physical Science: Click here to enter text. / 3 / Choose an item. /
Physical Science Lab: Click here to enter text. / 1 / Choose an item. /
Natural Science: Click here to enter text. / 3 / Choose an item. /
Natural Science Lab: Click here to enter text. / Choose an item. / Choose an item. /
Humanities / English Composition I / 3 / Choose an item. /
English Composition II / 3 / Choose an item. /
Foreign Language II: Click here to enter text. / 3 / Choose an item. /
Core History: Click here to enter text. / 3 / Choose an item. /
Core Literature: Click here to enter text. / 3 / Choose an item. /
English Elective: Click here to enter text. / 3 / Choose an item. /
History Elective: Click here to enter text. / 3 / Choose an item. /
Philosophy Elective Click here to enter text. / 3 / Choose an item. /
Fine Arts: Click here to enter text. / 3 / Choose an item. /
Additional Humanities: Click here to enter text. / 3 / Choose an item. /
Social Sciences / Principles of Macroeconomics / 3 / Choose an item. /
American Government / 3 / Choose an item. /
General Psychology / 3 / Choose an item. /
Introduction to Sociology / 3 / Choose an item. /
Anthropology or approved substitute: Click here to enter text. / 3 / Choose an item. /
Other / Computer Literacy: Click here to enter text. / 3 / Choose an item. /
Speech: Click here to enter text. / 3 / Choose an item. /
General Elective: Click here to enter text. / Choose an item. / Choose an item. /
General Elective: Click here to enter text. / Choose an item. / Choose an item. /
General Elective: Click here to enter text. / Choose an item. / Choose an item. /
General Elective: Click here to enter text. / Choose an item. / Choose an item. /
Field / SW 4916 / Field Practicum Seminar / 6 / Choose an item. /
SW 4926 / Field Practicum Seminar / 6 / Choose an item. /
TOTAL / Click here to enter text./124 Hours
Student Signature for Application / Printed Name / Date
Field Coordinator Signature of Application / Printed Name / Date
STUDENT CHOICES FOR PLACEMENT INTERVIEW
Student Name: Click here to enter text. / Initials: / Date: Click here to enter a date.
Agency Preference: List three agencies with which you wish to interview for your field placement. You may elect to list less than three. #1 will be considered your most preferred placement.
1. / Click here to enter text.
2. / Click here to enter text.
3. / Click here to enter text.
Please Note: It is the responsibility of the student, not the Social Work Program, to complete the necessary forms and the interview in the specified time periods. Securing acceptance into an approved field practicum agency is the social work student’s responsibility. Therefore, students should adhere to professional standards of dress, conduct, and comportment when presenting themselves in the interview.
Placement Process Guidelines:

Student completes Field Placement Application consistent with feedback provided by advisor and instructor for Senior Seminar/SW4713 and/or Field Coordinator, ensuring signed application, specified placement choices (ranking of #1-#3), and reviewed and signed Authorization to Release Information form.
Placement process for each student is then initiated with #1 choice for student including contact of potential Field Instructor in preferred agency by the Field Coordinator and sending of completed Field Placement Application for review should potential Field Instructor be willing to further assess student for appropriateness for placement.
Field Instructor determines upon review of application whether or not to accept call from student to set up an interview and communicates this with Field Coordinator. Should Field Instructor determine that a call from the student to set up an interview is appropriate, then Field Coordinator releases contact number to student and verbally affirms student to call to set up an interview; Should the Field Instructor determine that a call from the student to set up an interview is not appropriate, then the process for the student will resume with the next preference on the choice list.
Once the student completes an interview with a potential Field Instructor, the Field Coordinator will collaborate with the student and potential Field Instructor separately to determine a “good fit” for each party. Should both the student and potential Field Instructor express a “good fit” concerning the placement, with the student sharing affirmed preference for placement and the Field Instructor sharing affirmed offering of a placement opportunity, then the placement will be determined CONFIRMED. Should either the student or potential Field Instructor express concern about the placement being a “good fit” for either party, then the Field Coordinator will notify the other party. The student will resume the process with next preference on the choice list.
In the event that two or more students pursue the same placement opportunity, then the potential Field Instructor will review the applications for appropriateness and interview student(s) selected for interview. In the event that two or more interviews are scheduled with the potential Field Instructor, once the interviews are complete the Field Instructor should share with the Field Coordinator the student(s) affirmed as a “good fit” and each student should express separately to the Field Coordinator their preference for accepting or declining placement should it be offered. Multiple placements can be confirmed by one agency. In the event that only a portion of the students pursuing placement are confirmed, then the student(s) declined for placement will resume the placement process with the next choice.
Once a placement at an agency is CONFIRMED, the agency may no longer be pursued by other students.
The student may reserve the right upon discussion with and approval from the Field Coordinator to change choices.
If any placement agency is determined inappropriate by the Field Coordinator according to criteria specified in the Field Practicum Manual and/or if the Field Instructor is determined unqualified using criteria specified in the Field Practicum Manual, the Field Coordinator reserves the right to withdraw the agency and/or Field Instructor as a placement option.

AUTHORIZATION TO RELEASE INFORMATION
I, ______, authorize the Mississippi State University Social Work Program Field Coordinator to release field application and educational information to prospective Field Instructors. I understand this information will be used by the prospective Field Instructors and representatives of their employing agencies to assess my potential as a field placement student in the agency. Once I am confirmed for placement at an agency, I authorize reasonable and necessary written and verbal communication between the Field Coordinator and Field Instructor of the agency throughout the practicum process for adequate student monitoring and for supportive and evaluative purposes.
Student Signature for Release / Printed Name / Date
Witness Signature for Release / Printed Name / Date