______________________________________________________________________________
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
Application for Admission into the MSW Field &Practice Sequences
Name of Student:
Date:
Address:
Phone: (1):
(2):
E-mail Address:
ID #:991
Overall GPA:
Current Social Work GPA:
Students wishing to enter into the practice and field sequences of the social work major must complete an
application the semester prior to taking SOWK 605 (usually spring before beginning 605 in the summer).
Please address the following areas in reference to your readiness to begin the field and practice sequences.
Submit your typed responses to the Field Director. Please use headings so your responses may easily be
recognized.
1. Students are expected to have continued their development of the qualities identified on the
Application to the MSW Program (Full Time Advanced Standing students should address these
qualities even though admission was just granted). Please assess yourself in reference to the
qualities specified below (be specific).
a. Self-awareness
b. Professional commitment
c. Professional conduct
d. Empathy
e. Acceptance of diversity
f. Academic success
2. 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.
Please document your ability to comply with each of the following requirements. In other words,
discuss any recent issues or treatment related to alcohol or drugs, mental health, and/or
disabilities and address how you will:
a. Remain free from drug and alcohol dependency/misuse which interferes with the capacity
to learn or impairs the student’s judgment or performance either in class or in the field.
b. Remain free from mental health difficulties which interfere with the capacity to learn or
impair the student’s judgment or performance either in class or in the field.
c. Adjust to disabilities which interfere with the capacity to learn or impair the student’s
judgment or performance either in class or in the field.
3. Accommodations and needs. The following questions relate 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:
4. Commitment to complete the required hours. Students must block major portions of time each
week for field practicum experience.
For SOWK 605, approximately 27 hours per week (for 9 weeks) must be spent at the practicum
site for a minimum total of 240 hours by the end of the summer semester.
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:
5. Identify specific populations (e.g., children, elders, people with disabilities) or agencies with
whom you would prefer to work in your practicum. NOTE: Your request does not guarantee a
placement with the specific population but the request is taken into consideration.
6. 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.
7. Attach a current copy of your academic transcript.
8. Complete and attach the Student Agreement form (form Student 4) with the field application.
9. 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 affects the outcome, but it is possible for
students to be dismissed from the Program for severe violations.
10. 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 a cover sheet for your typed application packet and support documents.