California State University Long Beach

School of Social Work

Graduate Field Education Application - Second Year Field

Academic Year 2019 - 2020

Complete the application using Adobe, print it, attach your ID, and return it to the FIELD mailbox in SS/PA – 161 by December 15, 2018
- or –
Print the application, complete it by hand, attach your ID, and return it to the FIELD mailbox in SS/PA – 161 by December 15, 2018

----- Office Use Only -----

Tape or Glue Photocopy of Photo Identification Here. Date Agency ID Agency Name

(ex. CSULB ID, California ID, or Driver’s License)

Mark “x” for your current stipend programs.

Date (MM-DD-YY): 12/1/2018 CalSWEC PCW
SW 596 Field Liaison: Dr. Pringle-Hornsby UCCF
Note: If you marked “x” here only complete pages: 1, 2, 5, 6, 7, & 8.
Program Model Mark “x” for your Program Model
2 - Year Student X Mark “x” for each application you will submit.

3 - Year Student CalSWEC Mental Health

Note: Please submit all 10 pages of application. PPSC
LA County DMH X
Specialization Mark “x” for your Specialization GSWEC
CFW Place of Employment 2nd interview desired? __yes__no

IH X Notes:
- CalSWEC Mental Health and DMH must be outpatient.
AA - Additional applications are required for all 5 of the above.

First Name, Middle Name, and Last Name

Student ID
Home Address (Street, City, State, Zip Code)
Cell Phone
Home Phone
Work Phone
Email

Birthdate (MM-DD-YY)
Gender
Citizenship

If you plan to move, give approximate date and specific address of geographic location:
NOTE: If move will impact placement location, contact Field Education Department once your new home address is known.

AY2 Foundation Field Application (2019 – 2020) 1

I. Educational Background
Major Behavioral Science: Sociology
Undergraduate Degree Name of School Concordia University Irvine
Date Earned May 5th, 2018

Major
Other Graduate Degree Name of School
Date Earned

II. Professional Experience – Indicate all your human and social service experiences. Include your: undergraduate internship (if you
completed one), 1st year MSW internship, alternate internships, volunteer work, and other employment items. Please attach
additional page if necessary.

Agency or Organization Name Human Options

1st Year Agency or Organization Address
MSW Field Instructor Name Yvette Visconte, LCSW
Internship
Describe Learning Activities

Agency or Organization Name Covenant House Alaska

Agency or Organization Address 755 A Street Anchorage AK 99501
Start Date and End Date May 2016- Present (Seasonal)
Hours Per Week 30
Immediate Supervisor Name
A. Highest Social Work Degree Held by
Supervisor (ex. BASW, MSW, PhD, DSW, etc.)
Your Title
Your Position (ex. Volunteer, Internship, Paid)

Describe your responsibilities.

Agency or Organization Name

Agency or Organization Address
Start Date and End Date Hours
Per Week
Immediate Supervisor Name
B. Highest Social Work Degree Held by Supervisor (ex.
BASW, MSW, PhD, DSW, etc.)
Your Title
Your Position (ex. Volunteer, Internship, Paid)

Describe your responsibilities.

AY2 Foundation Field Application (2019 – 2020) 2

III. Language Ability - If you are able to interview and conduct assessments in a language other than English, please indicate your
additional language by marking “x” below.

Armenian Farsi Korean Russian Tagalog Other (specify below):

Cantonese Khmer Mandarin Spanish Vietnamese

IV. Social Work Career Goals

Question Write your response below.

What is the client population and type of agency in which you

hope to work with when you graduate from this program?

V. Priorities – For your second-year field experience, which of the items below is most important to you? Rank only those that apply
to you. 1 being the most important.
Item Your Ranking Specify the reason for your ranking below.
Agency/Population
Location
Day/Hours (indicate unavailability)

VI. Type of Placement

Question Write “direct” or “macro” below to indicate your response.
What is your preferred placement type: direct practice or Direct practice
macro practice?

Question Write your two options below to indicate your response.

If you wrote Macro, choose 2 of the following experiences:

o Administration and Communication N/A

o Community Organizing
o Policy Analysis
o Program Development and Planning
o Other, please specify:

Note: Each macro agency is likely to provide some but not all
of these types of experiences.

Question Write “Yes” or “No” below to indicate your response.

Do you plan to apply and use your agency of employment?

If yes, the Agency of Employment application is due to the No

Field Department no later than January 18, 2019. It is in
addition to this application.

AY2 Foundation Field Application (2019 – 2020) 3

VII. Type of Agency - In what type of agency would you like to be placed/interview? You may request specific agencies by indicating
the name next to your choice. Keep in mind that some may not be available or may have day, time, and/or language specifications.

Agency Type Choose 3 options and rank them 1st, 2nd, and 3rd below.

Addictions / Chemical Dependency

Community Based Family Service Agency

Corrections / Criminal Justice 2st

Developmental Disabilities

Foster Care/Adoptions (Non-CalSWEC)

GSWEC Agency

Health Care Related

Hospice

Homeless 3rd
Intimate Partner Violence
(requires state certified 40-60 hour training, could be in
summer; and hours may be in addition to field hours)
Mental Health Outpatient

Mental Health Inpatient

School (non PPSC)

PPSC (Students will receive 2 PPSC eligible sites unless
otherwise stated.)
Senior Center/Community Based Adult Services

Other, please specify: Transition Age Youth/Young Adults- 1st

For the agencies you indicated, please describe 2 learning goals you wish to achieve in your second-year field
placement:

Goal 1

Goal 2

AY2 Foundation Field Application (2019 – 2020) 4

VIII. Hours
Question Write “Yes” or “No” below to indicate your response.
Some agencies require students complete a total of 20 hours
per week. Would you be willing to meet this requirement?

IX. Location – Indicate the preferences you have regarding geographic areas for your agency. Use “1st Choice” and “2nd Choice” to
indicate your two preferences. Keep in mind, expectations regarding transportation are initialed on page 7.
Location Write “1st” or “2nd” below.

Los Angeles: (Includes Inglewood, South Central LA, Downtown LA, Hollywood)
Los Angeles: Westside (includes Santa Monica, Venice, West LA, and Culver City)
Los Angeles: East Los Angeles
Los Angeles: South Bay (includes San Pedro, Torrance, Wilmington, Carson)
San Fernando Valley
San Gabriel Valley (includes Pasadena)
San Bernardino
Riverside/Corona
Whittier / Norwalk / Santa Fe Springs / Pico Rivera / Downey
Pomona / Claremont / Ontario
Orange County
Long Beach 1st
Other (please specify):
Question Write your response below.
Goldenwest
Street
What are the major cross streets/major intersections near the Westminster Blvd
area which you will be traveling to and from placement?
If there is any additional information that is important for your
I hope to
receive a field
placement with
or at an agency
contracted with
placement, please explain. LA DMH.

X. Background
Most field placement agencies request security clearance evaluations, background checks, Live Scan finger printing, random drug screens,
etc. They may check for felony/misdemeanor convictions, either in the United States or in other countries, including driving under the
influence (DUI), acts of fraud, child abuse, elder abuse, domestic violence, assault, registration as a mentally disordered sex offender, or
having any professional license revoked. Please note that most agencies require students to pay the cost for background checks. Many field
placement agencies will not accept students with criminal records. Some agencies may accept students on a case-by-case basis as long as
they are open and honest about their legal background. For this reason, students must disclose on this form any criminal or other
background circumstance in order to assist us in matching you with an appropriate agency. Misrepresentation and/or omission
statements will be considered cause for immediate ineligibility for the CSULB Social Work Field Education Program.

* Please complete the following questions; If you indicate yes, a member of the field faculty will contact you for a confidential discussion.
* If you are unsure of the applicability of a past charge or conviction, including one(s) you believe to be expunged, err on the side of
indicating “yes” to enable us to have a further discussion.
Question Write “Yes” or “No” below to indicate your response.

Do you have any pending criminal charges (including DUI)? No

 Have you been convicted of any misdemeanor(s)? No
Have you been convicted of any felonies? No
Have you had a substantiated abuse or neglect report? No
AY2 Foundation Field Application (2019 – 2020) 5
XI. Accommodation
Question Write your response below.

Students who require an accommodation for field internship

must be registered with the CSULB Disabled Student Services
(phone: 562-985-5401 email: dss@csulb.edu).

Please describe any reasonable accommodation(s) you may

need due to a specific disability (e.g., not travel long
distances, accessible work space).

Accommodations are not given retroactively and must be N/A

documented with DSS in time for full participation in field. You
are not required to disclose your need for accommodations
before you are accepted for the placement; however it is in
your interest to make your best assessment of any
barriers/needs when you are at the interview. Once accepted,
you should tell the field instructor about your disability and let
them know what you need so as to have the maximum
opportunity to obtain any needed equipment/modifications.
Please do not wait until field begins. A Field Faculty member
may contact you for clarification if needed.

XII. Past History or Special Circumstances

Question Write your response below.
Are there any issues that should be considered in the
selection of your field placement agency? For example, are
there any personal, family, or health/mental health issues of
concern to you that might affect the agency or client
population selected for you?

Were there any challenges in your first year placement N/A

that should inform your 2nd year placement? (e.g.,
Performance Contract.)

XIII. Health Checks

Question Write “Yes” or “No” below to indicate your response.
Field placements must be planned in accordance with state
and federal laws and with consideration of field placement
agency policies, including the best interests of consumers.
Many field placement agencies now request physical
examinations, TB tests and/or immunization verification, and No
random drug screens. Please note that most agencies require
students to pay the cost for health checks. Use of medical
marijuana, even with a valid prescription, could rule out certain
placements due to federal guidelines.

Do you have any concerns related to the above? If you

indicate yes, a member of the field faculty will contact you for
a confidential discussion.

AY2 Foundation Field Application (2019 – 2020) 6

XIV. Transportation

Statement Initial
Students are responsible for their transportation to and from their field placement agency. Students using
their own cars can expect an average driving time of 45 minutes (each way) between residence and
agency. Prior to starting field, internship, students who plan to drive must show proof of a valid California
driver’s license and insurance meeting the State of California minimum requirements; and students must
maintain coverage throughout the entire internship period. The university does not assume responsibility MD
for any claims arising from the use of an automobile by a student during field internship. Students who plan
to drive but who fail to provide proof of coverage will not receive a field placement.

Initial the box on the right to indicate that you plan to drive and that you accept these conditions.

Students who do not have access to a car are responsible for transportation to and from the agency. Not
having a car will limit the options you have for placement.

Initial the box on the right to indicate that you plan to use public transportation and that you accept MD
these conditions.

XV. Proof of Car Insurance – If you initialed indicating you plan to drive, please include a copy of your driver’s license and car
insurance below.

AY2 Foundation Field Application (2019 – 2020) 7

XVI. Field Internship Student Agreement - The following statements are in accordance with the CSULB School of Social Work’s
policies and procedures. For further detailed information, please refer to the Graduate Field Education Manual. Please read the
following statements carefully, initial on the line after each statement to indicate your acceptance, and sign at the bottom of the
page.

Statement Initial
I hereby certify that the statements contained in this completed Field Education Application 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 my field
placement, separation from the field placement and/or initiate immediate disciplinary action, and dismissal from the MSW
program
I understand that any information contained in this field application and/or any pertinent information relating to my
professional student role shall be discussed between CSULB SSW faculty and approved field placement agencies and their
representatives.
I hereby give permission to the CSULB School of Social Work, Field Education faculty, and any agency that is willing to
accept me as an intern, to verify any and all information contained in this application.

I hereby agree to accept the field placement assigned by the field faculty of the School.

I understand that I am not entitled to a fourth field placement option if I have not been accepted at three agencies. I
understand that I would be asked to defer field education if this circumstance should arise. Additionally, other
circumstances that impact your placement acceptance may require you to defer field education.
I understand that I must be available for field placement 16 hours a week, (PPS and certain specified agencies may
require 20 hours). Placements are Monday-Friday during normal business hours. No weekend placements are
available.
I understand that I may not request or accept any arrangements to complete my time outside of the parameters
given by CSULB School of Social Work. Should an agency make any such request, I agree to check with my
assigned field consultant.
I understand different field placement agencies require different screening processes. Although these might not preclude me
from a field placement, it may affect my field placement options. I understand that the field agency where I am placed may
notify the School of Social Work’s Director of Field Education of negative results of these screens or background checks.

I understand that I must inform the Field Education Department should I have any criminal charges or convictions AFTER
completing this application and at any time during my field placement at CSULB.
I understand that I must inform the school if I have a potential dual relationship with anyone in either of the assigned
agencies, and a new agency will be assigned. (For example, if you have a personal relationship with someone in the
agency-friend, relative, or client.)
I understand that, if the situation arises in which I need to terminate my internship before completing my commitment, I
shall terminate in an appropriate, professional manner, as designated by the School of Social Work and as expected by the
agency. If I terminate prematurely, I am aware that I may not be placed in the same agency when I wish to continue my
internship. I understand that, should I terminate or be terminated prematurely due to my own actions, the School of Social
Work may not be able to locate another suitable internship experience for me and that my field education program may be
delayed at least one year.
I understand that, at all times in my field education program, I am expected to comply with the National Association of Social
Workers (NASW) Code of Ethics: being competent; demonstrating dignity, using integrity; demonstrating the importance of
human relationships; providing service; and advocating for social justice. I understand that failure to comply with these major
principles may result in my being ineligible to complete field education and, thus, be dismissed from the MSW Program at
CSULB.
I have reviewed and I understand all of the above statements. I agree to maintain compliance with the above statements,
the School of Social Work’s Graduate Field Education Manual and Graduate Handbook, and other policies and procedures
as developed by the School. I understand that the School of Social Work gave careful assessment to accepting me into the
program, and joins with me in working toward a successful educational experience.

Student Name
Student Signature (sign after printing form)
Date

AY2 Foundation Field Application (2019 – 2020) 8

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---------- For Official Use Only ----------

Reviewed By

Reviewed Date

Notes

AY2 Foundation Field Application (2019 – 2020) 9

 TO BE COMPLETED BY THREE-YEAR STUDENTS ONLY!

Seminar Day and Time Preference for Fall 2019

Second-Year Field Education SW 680 A/B

SEMINARS ARE SCHEDULED:

MONDAY, 5:00-6:45PM OR SATURDAY, 8:00-9:45AM

I am a Three-Year Student and my field seminar choice is:

Monday Evenings
5:00 pm – 6:45 pm

Saturday Morning
8:00 am – 9:45 am

My seminar instructor this year (first year field) is:

My concentration is:

Adulthood and Aging

Children and Family Wellbeing

Integrated Health

I understand that this choice is final and that I may not request a change after this form is completed:

Student Name

Student Signature (sign after printing form)

Date

AY2 Foundation Field Application (2019 – 2020) 10