Home School of Social Work: Field Education

Sunday, April 20, 2014

Field Instructor Application Form

INSTRUCTIONS: Please complete this form on your computer, then press the SEND INFORMATION button at the bottom of the form. This emails your information to the appropriate person at the PSU School of Social Work.

(1) Contact Information

First and Last Name:

Previous name(s) Used:

Work Phone: Other Phone:

Email:

(2) Organization Information

Agency/Program:

Street:

City: State: Zip:

(3) Have you earned a Social Work Degree?

  BSW School: Date:

  MSW School: Date:

  PhD School: Date:

(4) Are you currently a Licensed School Social Worker?

Yes
No

(5) Are you currently a Licensed Clinical Social Worker (LCSW)?

Yes
No

(6) Are you currently a Licensed Master Social Worker?

Yes
No

(7) Are you currently a Registered Bacccalaureate Social Worker?

Yes
No

(8) Professional Conduct (Responses are required.)

Have you ever been convicted of a felony, any sexual offense, or any offense involving a controlled substance or alcohol?

Yes
No

Have you ever been reprimanded or suspended from practice by any agency, employer, board, tribunal, etc.?

Yes
No

Have you ever been denied licensure/registration or certification to practice by any agency, employer, board, tribunal, etc.?

Yes
No

Have you ever been found to have violated any professional organization rules, by-laws, etc?

Yes
No

Has a judgment ever been entered against you in civil court for a practice-related complaint?

Yes
No

Are there any professional complaints against you currently pending or under investigation?

Yes
No

If you answered YES to any of the above questions, please type a detailed explanation in this space:

(9) Field Instruction, Supervision, or Teaching Experience: If your resume includes this information, please skip to next question.

(10) Please provide information on an individual who is familiar with your professional work (agency supervisor preferred)

Name:

Phone:

Email:

Position:

(11) Additional Relevant Information:

(12) Please check the appropriate box: (Your application will be e-mailed to the correct person).

Distance Option - Ashland, Central Oregon, Eugene, Salem Cohorts (Thet Mar Win)
Portland Campus Program (Jessica Hayes)
Child Welfare Partnership - (Laurie Leasure)

Electronic Signature

By typing your full name below, you are indicating that the information you have provided is true and accurate.

Your Full Name:

Date:

Thank you very much for your interest in becoming a Field Instructor at the School of Social Work!