Field Application for HPU Social Work (Fall 2021) Question Title * 1. Your name Question Title * 2. Your HPU Email Question Title * 3. Your HPU ID # Question Title * 4. What year will you be in the program in Fall 2021? BSW Senior MSW 1st practicum MSW 2nd practicum MSW Advanced Standing Question Title * 5. Which part of the Social Work program are you in? BSW On-Campus BSW MCP Program MSW On-Campus MSW Westside Cohort MSW MCP Program Question Title * 6. Where on Oahu do you live? (Town/Neighborhood) Question Title * 7. How will you get to practicum? Car Bus Other (please specify) Question Title * 8. Will you be working during placement? Yes, full time Yes, part time No Question Title * 9. Are you currently employed? Yes No Question Title * 10. If yes, who is your employer? Please enter below the times that you ARE available for practicum. (For example 9a - 5p) Question Title * 11. Monday Question Title * 12. Tuesday Question Title * 13. Wednesday Question Title * 14. Thursday Question Title * 15. Friday Question Title * 16. Saturday Question Title * 17. Sunday Question Title * 18. Is this your 1st or 2nd Practicum? 1st 2nd Question Title * 19. Please describe any volunteer experience that you have. (Organization, what your responsibilities were, approximate dates.) Question Title * 20. Please upload your resume here. PDF, DOC, DOCX file types only. Choose File Choose File No file chosen Remove File Please upload your resume here. Question Title * 21. Is there a specific agency that you are interested in working with? If so, please list: the name of the agency, a contact person and their telephone number. Question Title * 22. Please check the top 3 areas of social work that you are interested in.Please note: this is not a guarantee that you will get your first choice for practicum. Gerontology Children/Adolescents Homelessness Hospice/Palliative Care Criminal Justice Substance Use Veterans/Military Government/Legislature Program Planning and Administration Mental Health/Crisis Stabilization Other (please specify) Question Title * 23. Please select what part of the island you would prefer to do your practicum. Town (Honolulu) Windward Oahu North Shore Leeward (Pearl City to Kapolei) West Side (Kapolei to Makaha) Central (Waipahu to Wahiawa) Other (please specify) Question Title * 24. Have you gotten the COVID-19 Vaccine or are you planning on it? (There are some sites that may require vaccination.) Yes - I've received one shot. Yes - I've received both shots. Yes, but I'm still waiting. I have not decided. No, I am not planning on getting vaccinated. Other comments? Question Title * 25. Please provide any additional information that would be helpful in making your field placement assignment. Please answer the following questions openly and honestly. Your response is essential in the practicum office locating your practicum placement, making decisions for future practicum placements and for discussing your strengths and weaknesses in this profession. Question Title * 26. Have you ever been party to a civil lawsuit? Yes No Question Title * 27. If yes, please explain in detail. Question Title * 28. Have you ever been arrested or convicted of a misdemeanor or felony? Yes No Question Title * 29. If yes, please explain in detail. Question Title * 30. Are there any charges pending against you? Yes No Question Title * 31. Have you ever had an allegation of either child or adult maltreatment (abuse, neglect, abandonment, exploitation, and/or childpornography) made against you that was substantiated or is pending against you? Yes No Question Title * 32. If yes, please explain in detail. If you answered “Yes” to any of the above questions, you will need to meet with the Director of Field Education to clarify any questions. Additionally, you may be asked to provide documentation on the nature of the offense/allegation and its disposition and a statement containing proof of rehabilitation, if applicable. Question Title * 33. Please read the following and check below that you have read and understand the statements below:- I attest that all information provided in this application is true and accurate.- I am aware that a criminal background check will be performed, and given the results may impact my practicum placement and/or professional social work degree.- I understand that my application will be reviewed and discussed by HPU faculty to determine my readiness for practicum.- I understand that I may be required to show proof that I am TB negative, and/or complete a physical and provide other medical information as necessary.- I agree to follow the NASW Code of Ethics and HPU Practicum Manual.- I agree to comply with all the requirements of the practicum and at my site.- I understand that my resume will be released to potential field instructors, and I hereby agree to release all information contained therein. - I understand that any violation of the above stated requirements may result in my disapproval, suspension, or removal from the practicum experience. I have read and understand these expectations. I have read and don't understand these expectations Question Title * 34. Please enter your name and the date to "sign" this form. Question Title * 35. Please list the name, relationship and contact information of your emergency contact. Thank you for taking the time to fill this out. The next step is to schedule a time to meet with the Director of Field Education. You can sign up for an appointment time here: https://calendly.com/jessicagarlock/30min. Meetings will be done via zoom. Done