School of Social Work Appendix A - JOINT MSW FIELD APPLICATION

School of Social Work
APPENDIX A
Joint MSW Field Application

CLICK HERE TO GET 995 SOFTWARE INSTUCTIONS. CLICK ON THE LINKS AND FOLLOW THE DOWNLOAD PROCEDURE. DOUBLE CLICK EACH FILE TO INSTALL ON YOUR COMPUTER. 1. Fill out the form completely 2. File > Print 3. Select PDF995 as your printer 4. Press OK 5. Save file on your computer (ignore software window or 'X' to clear) 6. Email and send as an attachment to the appropriate person.
Date of Submission: Expected graduation date: Program: (check one) Full-time Part-time Advanced Standing Concentration: (check one) Micro Macro Field begins Fall semester: (Year) Instructions: Email and send as an attachment to the appropriate person. Name: (Ms/Mr/Mrs/Miss) University ID #: Permanent Address: Mailing Address: Email Address: Telephone: Permanent Present Work Cell
EDUCATION
Institution Name	Dates Attended	Degree Received
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COLLEGE
Name	Dates Attended	Degree Received
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WORK HISTORY: PAID EMPLOYMENT DURING PAST 2 YEARS
Employer NameAddressDates of Employment
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VOLUNTEER AND/OR COMMUNITY WORK DURING PAST 2 YEARS
Organization NameActivitiesDates
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FIELD EXPERIENCE FOR BSW DEGREE WAS OBTAINED AT
Name of AgencyAddressContact Person/Phone
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Health Information: Rate your general health: Excellent Good Fair Poor
Do you have any emotional or physical difficulties which require special arrangements in the field setting? No Yes (If yes, please explain below) Please Explain:
What foreign language(s) do you speak? Which foreign language(s) do you understand? Will you have the use of a car for field work? No Yes Do you have a valid Ohio Driver’s License? No Yes Are you presently employed? No Yes Full-time Part-time Hours per week: Place of Employment: Address: Telephone: Position: Nature of work performed: Work Schedule (indicate work hours): Monday Hours Tuesday Hours Wednesday Hours Thursday Hours Friday Hours Do you plan to work in the field? No Yes At the same job? No Yes Same schedule? No Yes Use this space to describe your professional social work areas of interest and/or career goals, which may influence your preference for a field placement. Thoughtful consideration will be given to your preferences. However, educational objectives and agency availability will be the determining factors in placement. Field at Placement of Employment: Under certain circumstances, a student may do field at her/his place of employment. The standards and requirements for this type of field placement are the same as those for all other placements in the Program. The proposed field instructor must be someone other than the student’s immediate employment supervisor; must have an MSW/MSSA degree with 2 years post-graduate experience; must have at least 1 year with the agency; and must be able to offer the student a minimum of 1-1½ hours per week of field instruction conference time. Also, the field experience assignments must be different from employment activity and be educationally focused. Students wishing to do a field experience at their place of employment, must, in addition to this application, submit a written Field at Place of Employment Proposal for approval by the Field Coordinator. (See Appendix B) Agency Name: Agency Address: Contact Person: Phone and Extension: I certify that the information on this application form is complete and accurate and that I hereby authorize it to be shared with the field instructor. I understand that acceptance into the Field Education Program is determined by the social work faculty and that satisfactory completion of field is a requirement for completion of the Master of Social Work degree and for graduation. __________________________________________________________________ __________________________________ (Signature of applicant) (Date)