Indiana University School of Social Work

Indiana University School of Social Work

S651/652 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 Only
Street Address (type below) / City, State (type below) / Zip Code (type below)
Home Phone (type below) / Work Phone (type below) / Cell Phone(type below)
Concentration

• Child Welfare
• Scholars
• Non- scholars
• Health
• Leadership
• Mental Health
• Schools

/ Placement Year ______/______
Month and year you plan on starting
Concentration Practicum
Placement Options – 640 HOURS

• Two Semester 16 hrs/16 weeks – 24 hrs/16weeks)
• Two semester 20 hours/32 weeks
• Two semester Extended 16 hrs/40 weeks
• One Semester Block (40 hrs/16 weeks)

PLAN on:

• Employment Based Practicum/Petition to follow
• International

/ Place of Employment:
Date Started:

Prior Education

University / Degree / Year
University / Degree / Year

PRIOR Social Work Placements

Organization / Field Instructor/Supervisor
BSW Junior Year
(if applicable)
BSW Senior Year
(if applicable)

MSW S555 Practicum ______

PRIOR Non-Social Work Placements

Academic Department / Organization / On-Site Instructor

Professional 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 Proficiency

Do you speak Spanish?
If yes, what is your proficiency level? / Yes / No
Do you speak another language?
If yes, please note ______/ Yes / No

Transportation

Is a car available? / Yes / No
Are car and driver insured? / Yes / No

Special Obligations

Are there any obligations that should be considered in planning a placement (e.g. child care, employment, scheduling, etc.)?

Yes / No

If yes, please explain:

651/652 Background History Addendum

Please answer the following questions. If you answer “Yes”, please provide explanation including, dates, charges, and outcomes.

1. 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.

1. 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.

1. 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.

1. 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?

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

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

1. 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 No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Activity Limitations

Do you have physical or other condition that will limit your activity or which should be considered in planning a placement?

Yes / No

If yes, please explain:

Requests for Adaptation

Students 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:

1. Sign a request for services based on the presence of a disability.
2. Provide appropriate diagnostic information that establishes that she/he is a qualified individual with a disability; and
3. Request 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?

Yes / No

If yes, please explain:

Other

Is 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 theconcentration 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 1 / Zone 2 / Zone 3 / Zone 4
 Gary
 Michigan City
 Rensselaer
 Valparaiso /  Goshen
 Plymouth
 Rochester
 South Bend
 Warsaw /  Angola
 Bluffton
 Columbia City
 Decatur
 Fort Wayne
 Huntington /  Crawfordsville
 Frankfort
 Lafayette
 Lebanon
Zone 5 / Zone 6 / Zone 7 / Zone 8
 Kokomo
 Logansport
 Marion
 Wabash /  Anderson
 Greenfield
 Muncie
 New Castle
 Richmond / Greencastle
 Terre Haute /  Indianapolis
Zone 9 / Zone 10 / Zone 11 / Zone 12
 Brookville
 Connersville
 Greensburg
 Rushville
 Shelbyville /  Bloomington
 Columbus
 Martinsville
 Mooresville
 Seymour /  Evansville
 Jasper
 Tell City
 Vincennes /  Lawrenceburg
 Madison
 New Albany
 North Vernon
 Scottsburg

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.

1. On a separate document, prepare an educational resume using the format provided at the end of this document.

1. 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 UNDERSTANDING

I 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 Handbook

I am aware I must attend the required field orientation prior to beginning practicum.

Student Name / Date

Social Work Student Field Placement Code of Conduct

Social 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 clients

Self 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 Name / Date

IndianaUniversitySchool of Social Work

S651/652 Practicum II - III

RESUME OUTLINE AND GUIDELINES

This 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 OUTLINE

1.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 OUTLINE

Name

Present address (include zip code)

Present telephone (include area code)

Beeper/Pager/Cell Phone numbers, if applicable

IUPUI 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 concentration

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

Additional 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

* * * * * * * * * * *

Field Placement Data Form

11/6/2018