Office of Field Practicum - Texas State University



TEXAS STATE UNIVERSITY School of Social WorkOffice of Field PracticumFIELD PRACTICUM INSTRUCTOR PROFILEWe appreciate your interest in becoming a Field Instructor with Texas State University School of Social Work. Please complete this form and send it to the Office of Field Practicum along with a copy of your most recent resume/vita. Note: Please fill out an individual form for each person applying as a field instructor within your agency.GENERAL INFORMATIONDate: FORMTEXT ?????Top of FormName of Person Completing Form: FORMTEXT ?????Bottom of FormName of Agency: FORMTEXT ?????Name of Program (if applicable): FORMTEXT ?????Mailing Address: FORMTEXT ?????City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ?????Telephone Number: FORMTEXT ????? Fax: FORMTEXT ????? E-Mail: FORMTEXT ?????PROFESSIONAL EDUCATIONDegreeMajor Year College/UniversityUndergraduate FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Graduate FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other Degree FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SOCIAL WORK EXPERIENCEHow many years of social work practice experience have you had at the bachelor’s level? FORMTEXT ?????How many years of social work practice experience have you had at the master’s level? FORMTEXT ?????SOCIAL WORKER LICENSING AND CERTIFICATION(S)Do you currently hold a Texas Social Worker License? FORMCHECKBOX Yes FORMCHECKBOX NoSpecify Texas Social Work License FORMCHECKBOX LBSW FORMCHECKBOX LMSW FORMCHECKBOX LCSW FORMCHECKBOX LMSW-AP SW License #: FORMTEXT ?????Are you a member of the Academy of Certified Social Workers? FORMCHECKBOX Yes FORMCHECKBOX NoPlease list other Licensing or Certifications: FORMTEXT ?????PROFILE: SOCIAL WORK PRACTICE EXPERIENCEDirect Practice FORMCHECKBOX Individuals FORMCHECKBOX Families FORMCHECKBOX Groups FORMCHECKBOX Other: FORMTEXT ?????Indirect Practice FORMCHECKBOX Administration FORMCHECKBOX Community Organization FORMCHECKBOX Program Development Research Supervision FORMCHECKBOX Consultation FORMCHECKBOX Other: FORMTEXT ?????LEVELS OF FIELD INSTRUCTIONIndicate the levels of field instruction that you are interested in providing. NOTE: For instruction of BSW students, you must have a BSW or MSW with two years of post-degree practice experience. For instruction of MSW students, you must have a MSW with two years of post-degree practice experience. FORMCHECKBOX BSW FORMCHECKBOX MSW Direct Practice (2nd year) FORMCHECKBOX MSW Foundation (lst year) FORMCHECKBOX MSW Administration/Supervision (2nd year)TEACHING PHILOSOPHYDescribe your philosophy/techniques about supervision, especially as it pertains to field practicum instruction with social work students: FORMTEXT ?????DEMOGRAPHIC INFORMATION Gender: FORMTEXT ?????Ethnicity: FORMTEXT ????? LANGUAGE ABILITIESBilingual: FORMCHECKBOX Yes FORMCHECKBOX NoLanguage: FORMTEXT ?????Thank you for taking the time to complete this form. Please email this completed form and a copy of your resume/vita to the Field Coordinator, Karen Knox at kk07@txstate.edu or by mail to:Field Practicum CoordinatorTexas State University-San MarcosSchool of Social Work601 University DriveSan Marcos, TX 78666-4616 ................
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