EAST TENNESSEE STATE UNIVERSITY
DEPARTMENT OF SOCIAL WORK
APPLICATION FOR BSW FIELD INTERNSHIP
The Field Education Office initiates the placement process for all BSW students. The process for
placement begins during the semester prior to the field internship and includes completion of the field
application, development of a resume and having individual contact with the field staff. The student will
also complete an agency visit and interview prior to beginning their internship.
REVIEW PROCESS:
Please submit this completed form to the Field Office (see address below) by _______________. Attach
one copy of your current resume (which must be typed) and a photocopy of your current valid driver’s
license.
Every student is required to pay a $17.50 fee which covers professional liability insurance. Please make
your check or money order (no cash or credit cards please) payable to "ETSU – Social Work". You will
not be considered eligible to enter field until the fee is paid.
You will be expected to schedule an interview with the Field Office. A signup sheet will be posted
outside of the Field Office (address below) beginning ____________________________. Your internship
options will be discussed during this interview. FAILURE TO SCHEDULE THIS INTERVIEW
DURING THE DESIGNATED TIMES WILL BE VIEWED AS A LACK OF READINESS FOR
PLACEMENT AND WILL RESULT IN A DELAY OF PLACEMENT.
Unless there are extenuating circumstances expressly stated on your application, you should expect a
placement within a 50 mile radius of Johnson City.
Please fill out this application as completely as possible. The information will become a permanent part
of your student file.
I, ______________________________________, agree to have a copy of my resume and
(print name)
self profile/self assessment given to prospective field instructors. I also agree to comply with all agency
placement requirements, including criminal background checks and drug screens. I understand that as a
field experience student, I will be representing the University and my field experience agency in a
professional role. Furthermore, I agree to adhere to professional standards of conduct and appearance.
I have read and understand the above information.
__________________________________________________________
(Signature)
(Date)
If you have any questions or concerns about the application process for your field assignment, please
contact Karen Martin, Field Education Office, Lyle House, Room 209, 423-439-6005.
Rev. 6-11
NAME: ________________________________________________ STUDENT ID#: _______________
LOCAL ADDRESS: ___________________________________________________________________
(street)
_____________________________________________________________________________________
(city)
(state)
(zip code)
LOCAL TELEPHONE NUMBER: ___________________________ CAMPUS P.O. BOX ___________
HOME ADDRESS, IF DIFFERENT:______________________________________________________
_____________________________________________________________________________________
HOME TELEPHONE NUMBER: _________________________________________________________
CELL TELEPHONE NUMBER:__________________________________________________________
E-MAIL: _____________________________________________________________________________
ACADEMIC RECORD
Hours Completed: ____________ Overall GPA: __________ GPA in Social Work: __________
Semester/Year of Field Experience:__________________ Anticipated Graduation Date: _____________
Social Work Major Required Courses
Grade
Introduction to Social Work
Professional Values and Ethics
Cultural Diversity
Interviewing and Recording Skills
Human Behavior in the Social Environment I
Human Behavior in the Social Environment II
Social Welfare Policy and Services
Social Work Research
Social Work Practice I
Social Work Practice II
_____
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_____
_____
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_____
_____
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Cognate Courses
Introduction to American Government
Developmental Life Span Psychology
_____
_____
General Education Core: All courses complete? Yes _____ No______
If no, which courses need to be taken?_______________________________________________
______________________________________________________________________________
Rev. 6-11
SELF-PROFILE AND SELF-ASSESSMENT
Directions: Please provide a type written narrative in response to the following questions. Include the
questions so the reader can be aware of the topic. Be specific and thorough.
1.
Briefly summarize your own social history, including (at your discretion) your family
background, significant life experiences, special interests, achievements, etc
2.
What are your personal characteristics and strengths that contribute to your ability to be a
professional social worker?
3.
What are your personal qualities and attributes that might detract from your ability to be a
professional social worker?
4.
Give an example of a situation in which you experienced stress. How did you respond and how
might this affect the way you respond to others experiencing stress?
5.
Briefly describe any previous paid or volunteer social work experiences.
6.
Rate your comfort level (1 being least comfortable, 4 being most comfortable) in relating to
others in the following categories:
a.
b.
c.
d.
e.
f.
g.
h.
The opposite gender.
Physically challenged.
Developmentally delayed.
Psychiatric diagnosed.
Substance abuse diagnosed
Ethnic background different from your own.
Sexual orientation different from your own.
Religious beliefs (or non-beliefs) different from your own.
Discuss those areas where you feel least comfortable. How would your comfort level affect
your choice of field placement?
7.
What situations or types of clients might present values conflicts for you? How might this
affect your choice of field placement?
8.
What are your immediate and long term professional and educational goals?
Rev. 6-11
Field Internship Preference Form
Directions: Indicate the following which you would like to consider for your internship:
Activities
check ALL that interest you
Fields of Practice
identify TOP THREE fields in order of interest
Age Groups
check ALL that interest you
Activities:
Administration
Advocacy
After Care/Follow Up
Assessment
Behavioral Techniques
Case Management
Casework
Community Outreach
Community Work
Consultation
Crisis Intervention
Documentation
Evaluation/Research
Family Counseling
Group Work, Large
Group Work, Small
Home Visits
Individual Counseling
In-Service Training
Intake
Multidisciplinary Work
Program Planning
Referrals
Social History
Team Meetings
Termination
Treatment Planning
Other (describe)
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Fields of Practice:
Age Groups:
Adoptions
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Aging
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Child Welfare
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Courts/Corrections
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Developmentally delayed/
mentally challenged
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Families
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Foster Care
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Group Homes
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Health
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Homeless
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Hospice
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Juvenile Justice
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Long-Term Care
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Mental Health
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Physically Challenged
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Protect Serv, Adult
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Protect Serv, Children
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Schools
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Social Services
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Substance Abuse
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Terminally Ill
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Women
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Other (describe)____________
Infants
Pre-School Children
Children
Elem Sch Children
Adolescents
Young Adults
Adults
Older Adults
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Agencies:
If you are interested in
working in specific agencies,
please list them below:
__________________________
__________________________
__________________________
_________________________
_________________________
Do you have use of a car during your field semester? Yes ____ No____
Do you need any special accommodation due to a medical condition or disability? Yes ____ No____
If yes, please explain:
Have you ever been convicted of a crime (felony or misdemeanor) or do you have pending charges of such a crime
(felony or misdemeanor)? Yes____ No ____ If yes, attach a separate sheet explaining the situation and provide details
regarding final disposition of charges and date(s).
Have you been subject to any action by the ETSU Department of Social Work including an Academic Performance
Review or completion of the document “Behavior Incompatible with Social Work or Impeding Academic Performance”?
Yes ____ No____
Is there any additional information pertinent to your field placement that the ETSU Field Office or your prospective field
supervisor should know (includes any substance abuse issues, personal history or issues that may have a direct impact on
your field placement)? Yes ____ No____(If “yes”, be prepared to discuss during personal interview with the Field
Office.)
Rev. 6-11