January, 2016
Dear MSW Advanced Standing Student,
In order to plan for the Fall 2016
–Spring 2017 MSW Clinical Practicum placements, there are several steps in the process:
1. Complete the attached Clinical Field Practicum Application as directed. Enter data on the form, and print it out.
2. Mail or hand-deliver the completed application, along with your updated resume, by noon,
Friday, March 11 . Applications should not be faxed. Your interview time will not be honored unless your application is received on time.
If you are still undecided about starting the MSW Program, please contact Marcelle Shrake at marcelle.shrake@washburn.edu
or
785-670-2140.
3. After returning your application paperwork by mail or in person, call the Social Work office at 785-670-1616 (or drop by the office in Benton 412) to request a practicum placement interview. You will be assigned a Practicum Coordinator (either Professor Carolyn Szafran or Professor David Jensen) and offered an interview appointment time.
4. Please arrive on time for your interview, and be prepared to discuss your specific interests concerning the type and location of your prospective placement. Your Practicum
Coordinator will be happy to help you consider your options, but please carefully reflect on alternatives you wish to pursue prior to the meeting. Dress for your interview as you would for an employment interview.
5. Review the MSW Student Handbook (which can be found on the Degrees page of our department website ) prior to the interview with your Practicum Coordinator.
Thank you in advance for your prompt return of the application, which is an essential step in your continued educational development as a social worker. I look forward to meeting with you in the near future.
Sincerely,
Steve Spyres, LSCSW, CGP
Director of Field Practicum
(785) 670-2146 steve.spyres@washburn.edu
Washburn University

Department of Social Work

Benton Hall

Room 412
1700 SW College Avenue

Topeka, Kansas 66621

(785) 670-1616

FAX (785) 670-1027 www.washburn.edu/social-work

FIELD PRACTICUM APPLICATION (MSW Clinical)
Washburn University Department of Social Work
Fall 2016 - Spring 2017
This three-part field application must be completed and returned to the Social Work Office by noon,
Friday, March 11, 2016. Late applications may result in applicants not being placed.
If you are still undecided about starting the MSW Program, please contact Marcelle Shrake at marcelle.shrake@washburn.edu
or 785-670-2140. Your practice instructor will provide the Practicum
Director input regarding your readiness for field practicum placement.
Field Practicum marks the start of your professional social work career in the community. Two semesters of field experience in the same practicum placement are required. A three-hour field seminar class must be taken concurrently during the Fall Semester. You must pass both practicum and seminar the first semester to proceed to the second semester.
Practicum begins during the first week of each semester although some placements have orientation workshops before the semester begins.
Hours cannot be carried over into the next semester, nor can a student complete the practicum early.
Review the MSW Student Handbook for additional details before your interview with your assigned
Field Coordinator. Keep a copy of your completed application packet for your records.
Instructions for completing form: First, SAVE this document on your computer before completing it.
Type your information and answers into the gray shaded form fields and check boxes. Fields will expand as necessary. When all fields are complete, SAVE again, PRINT a paper copy and sign where indicated.
Attach your Resume (see Part 3) and submit all documents as your application packet. Keep a copy of your complete application packet for your records.
Name:
Mailing Address:
Date (mo/day/year):
City: State:
Telephone # (Home or Cell): (Day):
Zip:
Ext
MyWashburn Email: @washburn.edu
Current Employment -- Hours per week:
How many hours per week will you be employed during your two semesters of field placement?
Name of Employer:
If you are considering a practicum at your place of employment:

When did your employment begin? (mo/day/year)

What is your position title and area of responsibility?
Not currently employed
STUDENTS MAY NOT SEEK THEIR OWN FIELD PLACEMENT.
DO NOT CONTACT ANY AGENCY BEFORE YOUR PRACTICUM OFFICE INTERVIEW.

Indicate below which fields of practice interest you. Choose 3 areas, ranking them in order of preference with 1 = highest and 3 = lowest. It is important to understand that (a) practice areas may have a limited number of available openings, (b) evening/weekend practica and stipends are rare, and (c) students must inform the Practicum Office of prior/current relationships with agencies under consideration for practicum placement or other issues that may complicate placement.
Adult Welfare
Aging/Gerontology
Child/Family Welfare
FIELD OF PRACTICE PREFERENCE
Community Social Work/Advocacy
Disabilities
Substance Misuse/Addiction
Other (Specify):
Describe your strengths and limitations as they pertain to social work practice.
Indicate special circumstances that may affect practicum placement. Be aware the many placements require background checks or health screenings.

Write a brief statement describing what you will bring to the field practicum experience in each of the following areas. Use only this form.
1. Communication skills [oral, written, and languages in addition to English]
2. Practice related skills [assessment, planning, intervention/advocacy, evaluation]
3. Working under supervision and independently
On which area(s) of skill development would you like to focus as you enter practicum?
What helps you learn in new situations?
What would you like a field practicum to offer you?
Submit a one (1) page, typed or word-processed resume on white paper. Include information about your college education/degrees, awards or honors, work experience, relevant volunteer experience, and career goals. The information will be reviewed by Practicum Office staff as part of the placement process. The information on pages 3 and 4 and the resume will be shared with your prospective Field
Instructor prior to your interview at the assigned agency.
Student signature: _____________________________________________________________

Background History* : Please answer either “Yes” or “No” to the following questions. If you answer
“Yes,” please attach a written explanation for each “Yes” response.
1. Have you ever been convicted of a felony? Yes No
2. Have you ever been found guilty of or liable for fraud or deceit in connections with services rendered as a social work service provider by a civil or criminal court of law or board of a professional organization? Yes No
3. Have you ever knowingly aided or abetted a person, not a licensed social worker, in representing him/her as a licensed social worker? Yes No
4. Have you used any alcohol, narcotic, barbiturate other drug affecting the central nervous system, or other drug which may cause physical or psychological dependence, either to which you were addicted or upon which you were dependent within the last two (2) years? Yes No
5.
6.
Have you ever been diagnosed or treated for any physical, emotional or mental illness or disease, including addiction or alcohol dependency, which limited your ability to practice behavioral sciences with reasonable skill and safety within the past two (2) years? Yes No
Have you used controlled substances which were obtained illegally or which were not obtained pursuant to a valid prescription order or which were not taken following the direction of a licensed health care provider within the past two (2) years? Yes No
7.
Have you ever been found to be in violation of a professional association’s code of ethics or of a state licensing board’s rule and regulations or statues regarding professional conduct?
Yes No
8.
9.
Have you ever paid a judgment or settlement in a negligence action that concerned your social work profession? Yes No
Have you ever resigned from a professional association or surrendered your license to a state licensure board while an ethical complaint was pending against you? Yes No
10. Have you ever identified yourself as a social worker in Kansas (excluding student work)?
Yes No
I attest that I have answered the above questions truthfully. I understand that failure to do so may result in termination of the placement process and notification of such action to the Department
Chair. I understand that if any of the above information changes I will immediately notify the
Practicum Office.
____________________________________
Student signature Date
*Note : These questions are drawn from the Behavioral Sciences Regulatory Board State of Kansas
LBSW/LMSW application (pp. 2-3).