CHECKLIST
Due: by Friday, March 18th, 2016 by 4:00pm
Turn In:
Drop Box, Outside the Division of Social Work Office
Mariposa Hall, Room 4010
Your packet must be arranged in this order:
Order
1
Document
BASW Field Application
(Please keep a copy for your records)
2
Student Self-Assessment
3
Undergraduate Field Academic Prerequisite Form
4
Copy of your Unofficial CSUS transcript (include Fall 2015
Grades)
Resume
5
6
Demographic Form (for statistical purposes only)
*Located on the last page of the BASW Field Application.
Obtain from
Field Education Website - Forms
My Sac State : Student Center
http://www.csus.edu/careercenter/index.html
Career Center Handbook has many useful
resume writing information.
Field Education Website - Forms
*This checklist is a guide for you and does not need to be turned in.
Your Field Application will not be reviewed if the above-listed documents are not
attached. If you need help figuring out any of these items, you may meet with an
advisor.
Social Work Drop-In Advising Center
Mariposa Hall, Room 4012
Mondays 1 - 4pm
Tuesdays 10am - 4pm
Thursdays 10am - 1pm
Revised Mar 1, 2016
Page 1
Division of Social Work
ATTN: Field Education Program
6000 J Street, MRP 4010
Sacramento, CA 95819-6090
Phone: (916) 278-6943
www.csus.edu/hhs/sw/index.html
INSTRUCTIONS
 Due Date:
 Turn into:
 Be Neat:
 Referral:
Friday, March 18th 4:00 pm
The “Drop Box” outside of Mariposa Hall 4010
Type or write in black or blue ink.
You will receive your placement referral by email from Ryan Jones,
Field Administrative Assistant ryan.jones@csus.edu
PLEASE NOTE: BASW field placement days are typically on Monday & Wednesday, 8a.m. - 5p.m.
available during these hours, you may not be able to enter field.
STUDENT INFORMATION – Please Print
Last Name
DATE
First Name
M. I.
If you are not
/
/
CSUS ID# (required)
Address
City
State
Zip
Home Phone
Cell/Work/Msg. Phone (circle one)
Sac State E-mail Address (…..@csus.edu ONLY)
County and City you will be residing in Fall 2016
Other Language(s) Spoken (specify)
JOB-BASED PLACEMENT
Do you wish to apply to use your place of employment as a field placement? _____Yes ____No.
If “yes”, please email Dr. Chrys Barranti, Undergraduate Field Coordinator, to discuss before turning in a job
conversion or job-related placement application. Due date for applications: April 1, 2016
SOCIAL WORK 140A
What semester/year?______________ Who was/is your professor? _______________________
DOCUMENTED DISABILITY
If you have a disability and will be requesting reasonable accommodations in a field placement setting, please
check here ______
Students who intend to request a reasonable accommodation in their placement relating to a disability must have
their disability certified through the Office for Services for Students with Disabilities and Sacramento State
(SSWD). In addition, students seeking a reasonable accommodation should also contact Prof. Mimi Lewis,
Director of Field Education immediately so that she, in coordination with SSWD, may assist the student in
determining whether the requested accommodation is reasonable and/or whether the placement can provide the
requested accommodation For further information, contact the Office of Services for Students with
Disabilities, 916-278-6955.
Students should keep copies of this document for their records.
Revised Mar 1, 2016
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FIELD PLACEMENT INTERESTS
In which SERVICE AREAS are you interested? Indicating 1st, 2nd, and 3rd priority.
Optional: If you are interested in a specific agency within a category, you may write the agency’s name in the box.
_____ Aging or Gerontology (adult day
health centers, in-home support services,
nursing homes, senior centers)
_____ Services to Disabled People
(including developmental and physical
disabilities)
____School-Based Social Work
_____ Alcohol & Drug/Substance Abuse
services
_____Culturally-Specific Services (please
specify)
_____Mental Health (primarily services
for adults with chronic and serious
mental illness)
_____ Child Welfare (adoptions, foster
services, CPS)
_____General Human Services (homeless
& housing services, income &
employment assistance)
_____Youth Services (homeless youth
services, prevention services)
_____Community Organizing and
Advocacy
_____Health-Related (community health
centers, HIV/AIDS services)
Limited number at the bachelor’s level.
Hospital placements are not available at
the bachelor’s level.
Limited number of CPS placements at
the bachelor’s level.
_____ Criminal Justice
____Elementary ____Middle school
____High School ____College
_____ Victim Services
_____ Other (specify)
________________________________________________________________________________________
______________________________________________________________________________________________
Most settings require the use of a car. Do you have a car and a valid CA license? Yes____ No____
Are you willing to use your car in the course of placement duties (i.e., transporting clients)?
Yes____ No____
Have you ever been denied a professional license (not a driver’s license) or had a professional license suspended or revoked
because of a legal, professional or ethical issue? Yes _____ No _____ If you checked “yes”, please provide details on a
separate sheet and attach.
Students should keep copies of this document for their records.
Revised Mar 1, 2016
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GENERAL FIELD AGREEMENT INFORMATION
(Please initial on the line for each subsection)
____General Conditions of Placement Referral
Field education is a requirement of the Social Work undergraduate major and the master’s program in Social Work. The
Division of Social Work will work with students to identify educationally-appropriate placements. Students will have up
to three opportunities to successfully interview for a placement. Placements are assigned by the Division of Social Work
and are not chosen by the student. Students who, for any student-related reason, are not able to obtain a placement after
three interviews will be ineligible for field for that year and will not be allowed to enroll in the field course. Future eligibility
for field will be determined by the field faculty.
____Professional Conduct
Student interns shall be professional and act in accordance and compliance with the laws, social work values, ethics,
Sacramento State academic standards, the Division of Social Work Student Standards, and the NASW Code of Ethics – 1999
Revised, which govern social work practice. A significant breach of any of these standards is grounds for immediate
dismissal from the field placement and potentially the Social Work program.
____Felony/Misdemeanor Convictions
Depending on the conviction, students who have misdemeanors or felonies may find it difficult to obtain a field placement,
and/or future employment or licensure in social work. Most internship agencies will require students to undergo fingerprint
checks and some require extensive background checks. Thus, students should be advised that while the Division of Social
Work will provide a student with up to three referrals for a placement, it does not guarantee that a student will be accepted.
A history of felony or misdemeanor convictions may present a barrier to acceptance by any University approved agency
and may prohibit the student from completing the social work degree requirements. Students should be prepared to disclose
to potential field placement sites any criminal background which may appear through fingerprint or background checks.
Even when a student’s criminal record has been expunged information may emerge during a check and become an issue for
placement. Students should be prepared to discuss their backgrounds in the context of how they have grown and changed.
Prior to referral, students are required to discuss these matters with the Field Director or Undergraduate Field Coordinator
so that they may be directed to agencies more likely to accept them, and receive guidance in discussing their backgrounds
with potential internships sites.
____Other Potential Barriers to Placement
The following factors any also prevent a student from obtaining approval to enter field or successfully obtaining a placement:
 Student is not available for placement during regularly scheduled placement days and times. Undergraduate days
are typically Mondays and Wednesdays, 8:00 am to 5:00 pm.
 Student does not follow established procedures and timelines for obtaining a placement.
 Student exhibits serious academic difficulties, inappropriate or unprofessional behavior, inadequate baseline level
of competence, emotional instability, or unethical behavior. See Student Standards for complete discussion.
____Approval for Field
The Field Director, in consult with Undergraduate Field Coordinator, makes the ultimate determination of whether a student
will be approved to enter field. Students assessed as not being ready for field will be notified in writing by the Field Director.
Students may appeal this decision to the Director of the Division of Social Work in writing within two weeks of the student
being notified that he or she is not eligible for field. If a student declares that he/she is not ready for field, the Field Director
may propose a plan to the student to increase his or her readiness. If the student decides to re-apply for field in a subsequent
year, the student will be required to provide evidence of improvement in the areas identified in the plan. Depending on the
severity of the reasons, the Division may determine that a student may not re-apply for field in subsequent years.
A separate process for students who are discharged from a field placement due to performance reasons is described in the
Curriculum and Policy Guide for Field Education, available on the Field website.
Students should keep copies of this document for their records.
Revised Mar 1, 2016
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FIELD PRACTICUM STUDENT AGREEMENT
(Please initial on the line for each subsection)
The following statements are in accordance with Sacramento State Division of Social Work's policies and procedures. For
further detailed information, please refer to the Curriculum and Policy Guide for Field Education located on the Social
Work website. Please read the following statements carefully, and initial at the bottom of each page.
1. ____I hereby give permission to Sacramento State, Division of Social Work, Field Education Program, and its faculty, to
verify any and all information contained within this application. This can include contacting former employers, field
practicum agencies, and/or field instructors, reviewing school records, etc. I understand that should any information affect
my professional student status, and/or internship role and thus the field practicum experience, the Division of Social Work
shall be authorized to assess and discuss the information with the appropriate parties. In doing so, I consent to Sacramento
State the release of the above referenced records within its possession and/or control that may constitute educational
records under the Family Educational Rights and Privacy Act (FERPA) of 1974 and by so consenting waive any right to
privacy I may have in said records under state and/or federal law. I also understand that I am entitled to a copy of any
records released by Sacramento State pursuant to this consent. I further authorize any former employers, field practicum
agencies, field instructors, and/or current or prior educational institutions I have attended to release the records identified
herein.
2. ____I understand that in order to be considered for a field practicum, I may be required to submit an application and/or
resume to potential field practicum agencies at their request. I also understand that I must provide accurate and complete
information to any potential field practicum agencies at all times concerning my background and qualifications for said
placement. I authorize any of the approved field practicum agencies or field instructors to verify any information included
in the materials I submit to them as part of any application to their placement.
3. ____I understand that most field practicum agencies shall request some or all of the following: security background
investigations, fingerprint checks, random drug screens, physical examinations, TB tests, immunization verification, valid
CA driver's license, etc. as requirements for their placement interview process and for practicum site confirmation.
Agencies may also require random drug screening(s) at any time during the year. I am willing to participate in these
additional screens/evaluations and give permission for the results to be provided to Sacramento State when requested. I
also understand that if I fail these screens, I will not be confirmed at the specified agency, can become ineligible for field
practicum, and therefore not be placed for an entire academic year. I also understand that if during the year I fail a
screening, I will be removed from the agency and not placed in another agency for the remainder of the academic year.
The Field Education Faculty will review my case to determine whether I am eligible to continue the program, and if so,
the timeline for returning to field. I understand that failing a drug screen(s) or other agency screening may be grounds
for disqualification from the Social Work Program.
4. ____I understand that the Division of Social Work does not guarantee that I will obtain a placement and I understand the
potential barriers to placement explained in the preceding section. I also understand that if I am unable to obtain an
approved placement or if the Division assesses that I am not eligible to enter field, I will not be able to proceed into the
Field Education course and may not be eligible to proceed in the Social Work program.
5. ____I shall fulfill the responsibilities of the student intern role and be in compliance with all field policies and procedures
as outlined in the Curriculum and Policy Guide for Field Education.
6. ____I will not contact agencies on my own to arrange a field practicum unless with permission of the Field Director or
Undergraduate Field Coordinator.
7. ____At all times, I shall maintain professional conduct in accordance with Sacramento State’s academic and conduct
standards, the Division of Social Work’s Student Standards, the NASW Code of Ethics, and professional social work
values.
8. ____If I need to terminate the internship before fulfilling my commitment, I shall terminate in an appropriate, professional
manner as designated by Sacramento State and assigned agency, and provide written and verbal notice as required by
Sacramento State and the agency. I understand that any such termination will be done according to procedures outlined
in the Curriculum and Policy Guide for Field Education. If I terminate prematurely, I am aware that I may not be eligible
for placement until the next academic year and that I will not be placed in the same field setting as previously assigned.
Revised Mar 1, 2016
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I have reviewed and understand all of the above statements and preceding information and agreed to be in compliance with
all of the above, with the Curriculum and Policy Guide for Field Education, and with the NASW Code of Ethics. If I am
not in compliance with the Division of Social Work’s policies and procedures, I understand that I can be considered
ineligible for field practicum. I certify that the information contained in this field application packet is true and correct to
the best of my knowledge.
Last Name: ____________________________________ First Name: _________________________________
(PLEASE PRINT)
(PLEASE PRINT)
Signature: _________________________________________________________________________________
Date:_________________________
Students should keep copies of this document for their records.
Revised Mar 1, 2016
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