Background Disclosure
I, ________________________________________________________, have informed my advisor
or the Social Work Program Coordinator of the following issue(s), which I understand could be
potentially detrimental to my placement in a social work practicum, to my professional reputation or
my ability to become a licensed social worker (For example, arrests, convictions, agency conflict of
interest).
________ (initial here) There are no such issues in my background. I understand it is my
responsibility to inform my advisor or the Social Work Program Coordinator of any future changes
that could potentially influence my status in the program.
Student: ______________________________________________________________
Date : _________________