5400 Campanile Drive, San Diego, CA 92182-4119 ~ (t) 619-594-6865 ~ (f)619-594-5991~
http://socialwork.sdsu.edu/index.php
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MSW I Foundation Year Application (SW 650 Field Practicum Course)
2012-2013 Academic Year
Please complete this form and return it by due date to the School of Social Work Central Office, HH-119.
School of Social Work
San Diego Sate University
5500 Campanile Drive
San Diego, CA 92182-4119
Attn: Field Education
MANDATORY
Attach Passport Type
Photo Here
TYPE OR PRINT LEGIBLY IN BLACK INK ONLY. Complete all areas. Students requesting
use of your employment sites as foundation year field practicum, please indicate this by writing
“Requesting Employment Site for Field Practicum” at the top of Page 1 on the MSW I Field Application
and schedule an appointment with Candy Elson immediately for consultation and the additional required
field paperwork. Remember to make 2 copies of this Application (1 copy to submit to agency at time of
interview and 1 copy to retain for your own future use).
Red ID #:
Date of MSW I Application:
Name:
Date of Birth:
First
/
/
Last
Permanent Address:
City:
State:
Zip Code:
Permanent Telephone:
Gender:
Email:
Mobile:
Ethnicity:
Citizenship:
Note: Remember to send address, phone, and email changes during 2011-12 academic year to: Social Work Field swfield@mail.sdsu.edu.
MSW Program Information
Program Status:
2 Yr. Program
3 Yr. Program
4 Yr. Program
Specialized Programs:
Joint MSW/MPH
Joint MSW/JD
Title IV-E Applicant?
Focus Area: Although you are not choosing a focus area specialization in the first year, rank on a scale from 1 to 4 (1 being most desirable,
4 being least), all areas that interest you at this time.
Aging
Behavioral Health (MH)
Child Welfare
Health
International
______________________________________________________________________________________________
For SDSU SSW Use Only
Application Received:
Data Entry:
Field Placement:
Program/Unit:
Location Site Address:
Agency Telephone:
Field Instructor:
Telephone:
MSW I Field Practicum Application 2012-2013
Conf:
Email:
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The following information assists the SDSU Field Education Faculty in guiding our selection of your foundation year placement
with your experiences, interests and goals. Please note that this does not guarantee that you will be placed solely by your
input provided below.
Geographic Preference
Note: Students can expect an average driving time of 60 minutes (each way) between your residence and field practicum site.
List in order your 4 most preferred locations. Use “1” for the most preferred, “2” for the next preferred, etc.
City of San Diego
East County
North County Inland
Imperial Valley
South Bay
North County Coastal
Transportation_________________________________________________________________________
The student must be able to show proof of adequate automobile insurance, meeting the minimum State of California
requirements, and a valid California Driver’s License upon request from the agency. Most settings require the use of a car.
Do you have a car?
Yes
No
Language Fluency______________________________________________________________________
Are you fluent in a language other than English?
Total Fluency?
Yes
No
Yes
No
If yes, which one(s)?
Only Conversational Ability?
Yes
No
Academic Accomodations_______________________________________________________________
Students who intend to request academic accommodation for their disabilities are required to contact the Director of Field
Education, via email, immediately (before the interview process) to discuss specific accommodations for which they have
received authorization. When a student is requesting accommodations for his/her internship, the student is required to
automatically consult with SDSU Student Disability Services (SDS) office for evaluation, verification and/or assistance in
accommodations being requested.
In order to assist the student in his/her practicum confirmation, written accommodations from SDSU SDS must be submitted to
Candy Elson by the student before internship interviews are completed. Please contact SDSU Disabled Student Services at
619.594.6473, http://www.sa.sdsu.edu/sds/, Calpulli Center, Suite 3100. Please note that your graduate advisor, Dr. Lucinda
Rasmussen is available to expedite a student’s referral to SDSU SDS. Please refer to “Field Placement Process Policy Special Accommodations Section” in Field Education Manual for further details.
Circumstances Regarding Clearances_____________________________________________________
Student interns shall be professional and act in accordance and compliance with the laws, social work values, ethics,
and School academic standards, including the NASW Code of Ethics-1999 revised
(www.socialworkers.org/pubs/code), which govern social work practice. Felony / misdemeanor convictions depending on
the severity, duration, time frame, type, can lead to: an academic year delay in field placement; immediate field practicum
ineligibility; and/or disqualification from the School. Each case is reviewed in relationship to the requirements of the SDSU
School of Social Work policies, curriculum requirements, laws, ethics and values directing the standards in the social work
profession. Misrepresentation and/or omission statements will be considered for immediate ineligibility for the SDSU
SW Field Education courses.
Please complete the following questions:
1. Have you ever been convicted in the U.S. or abroad of a crime that is related to the ethical responsibilities and standards of
a social work professional as described in the NASW Code of Ethics?
Yes
No
2. Have you ever performed an act involving dishonesty, fraud, or deceit in the U.S. or abroad with the intent to benefit yourself
or another, or with the intent to injure another?
Yes
No
3. Have you been convicted of any crime in the U.S. or abroad involving child abuse, elder abuse, domestic violence,
assaultive or abusive issues?
Yes
No
MSW I Field Practicum Application 2012-2013
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4. Have you ever been ordered to register as a mentally disordered sex offender or the equivalent in the United States or
abroad?
Yes
No
5. Have you ever been denied a professional license or had a professional license revoked because of a legal, professional, or
ethical issue?
Yes
No
If you answered “yes” to any of the questions in this section, please provide an explanation: identify the issue(s),
date(s), occurrence(s), place, rehabilitation, restitution, etc. Please attach a separate sheet of paper to address the
above.
NOTE: A field practicum application for a student intern position may be denied on the grounds that the applicant knowingly
made a false statement of fact required to be revealed in this application. Therefore, if you are unsure of the applicability of a
past crime to the ethical responsibilities and standards of a social worker, err on the side of including the information.
Career Goals_________________________________________________________________________
Briefly describe tentative career goals and areas of special interest.
1.
2.
3.
Educational Summary________________________________________________________________
Undergraduate Degree Major:
Location (City and State or Country):
School:
Graduation Month and Year:
Other Advanced Degree Major:
Location (City and State or Country):
School:
Graduation Month and Year:
Prior Professional Experience__________________________________________________________
List prior human service experience (volunteer, internship, and employment), starting with most recent.
DATES
AGENCY/ ADDRESS / PHONE
FROM
Mo. Yr.
TO
Mo. Yr.
HOURS PER
WEEK
EMPLOYMENT, INTERNSHIP, OR
VOLUNTEER?
TO
Mo. Yr.
HOURS PER
WEEK
EMPLOYMENT, INTERNSHIP, OR
VOLUNTEER?
1.
Position / Duties:
DATES
AGENCY/ ADDRESS / PHONE
FROM
Mo. Yr.
2.
Position / Duties:
MSW I Field Practicum Application 2012-2013
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DATES
AGENCY/ ADDRESS / PHONE
FROM
Mo. Yr.
TO
Mo. Yr.
HOURS PER
WEEK
EMPLOYMENT, INTERNSHIP, OR
VOLUNTEER?
TO
Mo. Yr.
HOURS PER
WEEK
EMPLOYMENT, INTERNSHIP, OR
VOLUNTEER?
3.
Position / Duties:
DATES
AGENCY/ ADDRESS / PHONE
FROM
Mo. Yr.
4.
Position / Duties:
Additional Training___________________________________________________________________
Briefly list any additional training, courses, institutes, workshops, and special learning experiences. Include dates of
attendance.
Additional Information_____________________________________________________________________
Optional.
MSW I Field Practicum Application 2012-2013
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San Diego State University - School of Social Work
MSW I – Foundation Year (SW 650) Field Practicum Student Agreement
2012-2013 Academic Year
The following statements are in accordance with the SDSU School of Social Work’s policies and procedures. For further detailed information,
please refer to the Graduate Student Handbook and the Field Education Manual.
Please read the following statements carefully, and sign at the bottom of the page:
1.
Application Verification: I hereby certify that the statements contained in this completed Advanced Field Practicum Application and any
other information included as part of this application and attachments are true and correct. I agree and understand that any
misrepresentation or omission of any material facts on my part may be cause for delay in field placement, separation from the field
practicum, and/or can initiate immediate disciplinary action, and dismissal from the MSW program.
I hereby give permission to the SDSU School of Social Work, Field Education Department, and its faculty members, and any of the
approved field practicum agencies or field instructors to verify any and all information contained within this application. This can include
contacting former employers, field practicum’s, and/or field instructors, reviewing graduate school records, etc. Please be advised that if
any information should come to our attention, which can affect your professional student status, and/or internship role and thus the field
practicum experience, the School shall be authorized to assess and discuss the significant information with the appropriate parties.
2. Communication: I understand that any information contained in this field practicum application packet and/or any pertinent information
relating to my professional student role shall be discussed between SDSU faculty and approved field practicum agencies and their
representatives.
3.
Agency Clearance(s): I understand that most field practicum agencies request 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 and that I, as the student, will be responsible for said cost of the
evaluation. 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 the School 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 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 Director of Field Education and assigned Field Faculty Instructor 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 MSW Program.
4.
University and SSW Policies: I shall fulfill the responsibilities of the student intern role, be in compliance with all School Policies and
Procedures as outlined in the Field Practicum Application, the Field Education Manual, the Graduate Student Handbook, and the
Graduate Bulletin. I understand that SW 650 is a year-long course and I will be attending for fall and spring semesters in the academic
year.
5.
Professional Conduct: At all times, I shall maintain professional conduct in accordance with the School’s academic standards, i.e., the
NASW Code of Ethics, professional social work values, and laws regulating social work practice.
6.
Conflict of Interest: As a social work student, it is considered to be a conflict of interest to engage in a field practicum in an agency
where you and/or a family member have been a CLIENT and/or an EMPLOYEE. Thus, social work students may not be placed in an
agency where they or a family member have worked, gone to school, or received services such as medical care, mental health se rvices,
employment assistance or child welfare services. I understand that it is my responsibility as a social work student to inform the Field
Education Coordinator of a potential conflict of interest AND to decline a placement in which there is a conflict of interest.
7.
Termination: If the situation arises and I need to terminate the internship before fulfilling my internship commitment, I shall terminate in
an appropriate, professional manner as designated by SDSU and assigned agency, and provide written and verbal notice as required by
SDSU and the Agency. I understand that any such termination will be done only with the written approval of the SDSU SSW and the
Agency as outlined in the manual.
I have reviewed and understand all of the above statements and have agreed to be in compliance with all of the above, the School
Policies and Procedures, the Field Education Manual, the Graduate Student Handbook, and the NASW Code of Ethics. If I am not in
compliance with the School’s policies and procedures, I understand that I can be considered ineligible for Field Practicum.
Please Print: Last Name:
First Name:
Signature:
Date:
MSW I Field Practicum Application 2012-2013
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Please do not include this page with your field application form.
MSW I – Foundation Year Application Due Dates:
For 3 Yr. and 4 Yr. Students Enrolled in MSW Program in Fall 2011 ONLY:
Submit completed MSW I - SW 650 Field Application in its entirety between February 20th to February 27th, 2012
Deadline is 4:30pm on February 27th, 2012 to Social Work Central Office - HH 119.
Attn: Field Education
For Incoming 2-Year MSW Students Enrolling in MSW Program in Fall 2012 ONLY:
Mail or bring completed MSW I - SW 650 Field Application in its entirety by the same day your “MSW Program Verification”
form is due (within one week) from date of acceptance letter to School Address (on front of Field Application Form).
Attn: Field Education. The field application may be scanned and sent electronically, but it must be signed and have photo
image attached. (Hard copy by mail to follow electronic copy is preferred.) swfield@mail.sdsu.edu
MSW I – Foundation Year Field Practicum Application Checklist
The following is a guide to assist you in completing the MSW I Field Practicum Application materials.
This page does not need to be handed into the School.
Have you 
 Completed the MSW I - SW 650 Application Form (5 pages), including
Attached a Passport Type Photo to front page
Personal Information
MSW Program Information
Applicant Information
Educational Summary
Prior Professional Experience
Career Goals
Additional Training
Additional Information (Optional)
 Read and signed the MSW I Field Practicum Student Agreement – page 5.
 Xeroxed 2 copies of the entire Field Application Packet, retaining these copies for yourself
(1 copy for the Agency-Field Instructor interview and 1 copy for your future use).
 Begin preparation of a professional resume.
MSW I Field Practicum Application 2012-2013