______________________________________________________________________________
College of Health and Human Services
Department of Social Work
Field Education
749 Chestnut Street
Terre Haute, Indiana 47809
Telephone: 812-237-2322
Fax: 812-237-8114
MSW Clinical Field Placement Request
Student Name:
Street Address:
City/State:
School Telephone:
Cell phone:
MSW Concentration:
Please answer the following questions to assist the Field Director in securing your field
practicum site.
1. Students must remain free from drug and alcohol dependency/misuse, mental health
difficulties, or disabilities which interfere with the capacity to learn or impair the
student’s judgment or performance either in class or in the field.
Have there been any changes since your initial application into the field sequence last
year?
No
Yes. If so, please explain in detail.
2. Accommodations and needs. The following set of questions related to unique situations
that need to be shared with the Field Director in preparation for your field practicum
experience. Examples include disabilities and any issues related to course prerequisites.
NOTE: Further discussion and plans for accommodation will be discussed upon
acceptance for field placement.
a. Location of Placement – Do you desire your placement to be in or to exclude a
specific community? If so, please provide details sufficient to aid in your
placement.
b. Transportation - Do you have an automobile available to get to/from your
practicum site?
Yes
No – identify transportation plans
c. Legal factors that limit placement options – Several agencies require a limited
criminal background check prior to beginning a field practicum.
i. Do you anticipate difficulties in being approved to work at an agency after
a background check is completed?
No
Yes If yes, explain in detail:
ii. Have you been convicted of or pled guilty to a violation of a federal or
state law or are criminal charges pending?
No
Yes If yes, explain in detail:
iii. Have you ever been arrested or had any charges filed against you?
No
Yes If yes, explain in detail:
d. Other factors that affect placement options.
i. Do you have a disability or other conditions/situation that would limit
your activity or should be considered in planning a field placement?
No
Yes If yes, explain in detail:
If yes, have you registered your needs with Student Support Services?
No
Yes
ii. Have you ever been fired from a job?
No
Yes If yes, explain in detail:
3. Commitment to complete the required hours. Students must block major portions of
time each week for field practicum experience.
For SOWK 610 and 615, placement involves approximately 25 hours per week (for 14
weeks), at the field practicum site for a minimum total of 350 hours each semester.
Do you anticipate difficulties in meeting the expectations outlines above?
No
Yes
If yes, explain in detail:
Are there any known issues that affect the hours that you can make available for
practicum?
No
Yes
If yes, explain in detail:
4. Identify agencies/populations you have worked with as a volunteer.
5. Rank the population with whom you would prefer to work in your practicum (e.g.,
children, elders, people with disabilities)
1st
2nd
3rd
6. Please rank your preferences if you know which agency or agencies you would like to
complete your field practicum (e.g., Division of Children Services, Hamilton Center,
Vigo County School Corporation)
1st
2nd
3rd
7. Attach a professional and comprehensive résumé.
Students are required to schedule and attend a session (not a walk in visit) with a career
counselor in the Career Center for guidance in creating a professional résumé.
8. Attach a current copy of your academic transcript.
9. Complete and attach the Student Agreement form (form Student 4) with the field
application.
10. It is not acceptable to knowingly withhold information that is a possibly relevant
limitation for the student’s placement consideration. If it is determined that a student has
knowing withheld relevant information from consideration in placement, the student may
be required to come before the Student Affairs Committee. Severity of the problem will
determine the outcome, but is possible for students to be dismissed from the Program for
severe violations.
11. Agreement: I understand that any information that is deemed important to the placement
will be shared with the field instructor/task supervisor. I am aware that many agencies
require criminal checks and health screening for students to be accepted in placements.
Declining an agency request for a criminal check or health screening is likely to limit my
placement options and may lead to my inability to complete the placement requirement.
Signing this document reflects the accuracy of your responses and your confirmation of the
above agreement.
_________________________________________ Signature ___________________Date
Use this document as the cover sheet and attach your application supplements before turning it in
to the Field Director.