California State University, Sacramento (CSUS)

California State University, Sacramento (CSUS)

Division of Social Work

Masters of Social Work Program (MSW)

Fall 2016

MSW APPLICATION AND CHECKLIST

Please return this checklist with your application packet

Division of Social Work
Use Only
☐ / 2016 MSW APPLICATION – DUE JANUARY 15, 2016
☐ / SPECIALIZED AREA OF PRACTICE SURVEY (final page following this application)
☐ / GRE ANALYTICAL WRITING SCORE
☐ / THREE REFERENCES ON REFERENCE FORM(In sealed envelope with signature of Referrer on flap). List names of references:
☐ / LIBERAL ARTS FORM (General Education) – Required only if Bachelor’s is from non UC or non CSU Institution.
☐ / UNOFFICAL TRANSCRIPTS (Reading the Instructions for Applicants to the MSW Program regarding transcripts is highly recommended)
☐ / OPTIONAL - Print-Out of Confirmation of CSU MENTOR Application submission

I, acknowledge that I submitted the CSU Mentor Application due on or before January 15, 2016.

Mail completed APPLICATION PACKET to: CSU, Sacramento

Division of Social Work

6000 J Street – Mariposa Hall #4010

Sacramento, CA 95819-6090

Attn: MSW Admissions

Page 1 of 5

FALL 2016 / CALIFORNIA STATE UNIVERSITY, SACRAMENTO
DIVISION OF SOCIAL WORK –MSW APPLICATION
Application material is confidential. Please print and use additional pages if necessary.
Email(SacLinkEmail Preferred if available) / CSUS Student ID (If available)
Last Name First Name Middle Name
Other Name(s), if different from above, that may appear on documents or records:
Present Address: (street & street number) (city) (state) (zip)
Home Phone:
( ) / Work Phone:
( ) / Mobile Phone
( )
Age: / Gender: ☐ Male ☐ Female ☐ Transgender ☐ Other
PLEASE CHECK ONE
I am applying to the:
☐Two Year Full-Time Program
☐Three Year Part-Time Program / Have you previously applied or been admitted to the MSW Program at CSUS?
☐no ☐yes
If yes, what year:
Are you currently enrolled at CSUS as a graduate student in another department?
☐no ☐yes, specify department:
I am applying to the Title IV-E Stipend Program ☐yes ☐no
If yes, please check one
☐2 year Full-Time MSW Program ☐3 year Part-Time MSW Program
Please download theTitle IV-E Stipend Program application:
(Available January 18, 2016 and due February 13, 2016by 4 PM)

List in chronological order (most recent first), all colleges and universities attended.

Name and Location of Institution / Mo/Yr of Attendance / Major / Degree
Earned / Mo/Yr
Received
(or expected)

Page 2 of 5

Cumulative GPA ☐ semester units only ☐ quarter units only ☐ combination of semester/quarter

Last 60 unit GPA ☐ semester units only ☐ quarter units only ☐ combination of semester/quarter

Calculate your last 60 unit GPA by using the most recent 60 semester units. If you have quarter units or combination of semester and quarter units refer to the Instructions for Applicants to the Fall 2016 MSW Program. Click here for the CSUSGPA calculator.

/6 GRE ANALYTICAL WRITING SCORE

Have you completed, or do you expect to complete a liberal arts (bachelor’s) degree from a UC or CSU?

☐Yes ☐No(If No, please fill out and attach the Liberal Arts form.)

Have you completed, with grade “C” or better, acceptable * courses in:

Introduction to Statistics? ☐Yes - Please list below ☐No - Please indicate expected completion date below*

Human Biology? ☐Yes - Please list below ☐No - Please indicate expected completion date below*

*See Instructions to Applicants to the Fall 2016 MSW Program for more information on “Acceptable” courses and deadlines for completion or see the MSW Application website for the same information

List the Statistics and human Biology course(s) and date(s) completed below or expected completion date

Course Number / Course Title / Institution / Term/Year / Grade / Date of Completion (or Expected Completion Date*)

List three or more courses specializing in cultural diversity. Course content should be related to modern populations you may interact with in your capacity as a social worker. For an example of cultural diversity coursesclickHERE.

Course Number / Course Title / Institution / Term/Year / Grade / Date of Completion (or Expected Completion Date)

Employment Record (paid)

List paid employment, full and part time, beginning with present or last position held. Designate full-time (F) or part-time (P). Use additional sheets

if necessary. Please do not include volunteer work or field placement in this category. Experience through December 31, 2015 will be considered. Make sure to add total hours and divide by 2000 to get yearly equivalent.

Name, phone number and location of employers in setting related to human services. / Title and Duties / Month/Yr. / Hrs./
Week / Total Hrs.
From / To

Sum of Total Hours

Total hours divided by 2000 =Yearly equivalent______

Page 3 of 5

Employment Record (paid) cont.

Name, phone number and location of employers in settings NOT related to human services. / Title and Duties / Month/Yr. / Hrs./
Week / Total Hrs.
From / To

Sum of Total Hours

Volunteer (unpaid) Activities and Experience in Human Services

Please list volunteer work experience in human services programs (e.g. social welfare, education, medical, recreational). List membership, offices, and responsibilities in organizations, community activities, etc. Include current and past activities that reflect your scope of interest and participation.

Organization, Phone Number, Name of Supervisor / Position / Nature of Activity / Month/Yr. / Hours/
Week / Total
Hours
From / To

Sum ofTotal Hours______

Undergraduate Field Placement: BSW Applicants Only

Agency / Nature of Work / Month/Yr / Total Number of Months
From / To

Page 4 of 5

List any special academic distinctions received (honors graduation, membership in honorary organizations, etc.)

• Do you have an MA/MS, Ph.D., or JD from a US-accredited American University or an equivalent international degree with coursework in the English language? ☐yes ☐no

• Have you published a refereed first – or single – authored academic journal article in the English language? ☐yes ☐no

• Were you ever the instructor of record of a college-level writing course taught in the English language at a US-accredited University? ☐yes ☐no

List any leadership positions held:

Do you speak a language other than English that will help you in serving a particular population in need of social services? What language?

______

Please discuss how you acquired the language skill and how will this language be used to serve the particular population.

Ethnic Identity (optional). Please enter a code

1American Indian or Alaskan native; tribe: L Laotian

2Black, non-Hispanic, including African AmericanVVietnamese

3Mexican-American, Mexican, ChicanoTThai

4Other Latino, Spanish-originSOther Southeastern Asian

ACentral AmericanGGuamanian

BSouth AmericanHHawaiian

QCubanNSamoan

PPuerto Rican6Other Pacific Islander

CChinese7White

JJapaneseFFilipino

KKoreanZUkrainian

RAsian IndianYRussian

5Other Asian8Other ______

OHmong9No response

MCambodian 10Decline to state

11 Bi racial ______

☐ Applicant Agreement: To my knowledge, the information I have provided in this application is true and accurate.

Signature of Applicant Date

Page 5 of 5

SPECIALIZED AREA OF PRACTICE SURVEY

For course planning purposes, we would like to survey your preference for specialized area of practice. This is only a tool to gauge applicant interest. Please select one specialization that most appeals to you or if you are uncertain select undecided.

The survey will not have any impact on your application to the Division of Social Work and will only assist the department in determining how many courses will be offered during the MSW II year of study for the applicant class of Fall 2016.

☐Behavioral Health/Mental Health Specialization

Social Workers are one of the principal providers of mental health services in the United States. There is an increasing need for advanced competencies to practice in mental health centers, psychiatric rehabilitation facilities, emergency services, hospitals, housing and residential recovery programs serving homeless, as well as dual diagnosed clients. The focus is to train graduate level practitioners to conduct complex assessments, be competent in differential diagnosis, using DSM 5, be able to perform time limited psycho-therapeutic supports, clinical case management, be able to fully integrate autonomous practice with full respect for advanced ethics and mental health law and be a liaison with the courts and other forensic services.

☐Health & Gerontology Specialization

The constant growth, demands and changes in health care have had a serious impact on the viability and need for social workers in all areas and settings of health care. Social workers are present in public health, acute and chronic care settings providing a range of services including health education, crisis intervention, a wide range of individual, family and group supportive counseling and case management. Health care social workers are increasingly trained to provide interventions to prepare for and respond to traumatic events and disasters. The health care system in the United States is complex and multidisciplinary in nature and Social Workers will be trained in a network of services such as diagnosis, treatment, rehabilitation, health maintenance and prevention provided to individuals of all ages with a range of needs.

☐Child, Adolescent, & Family Specialization

Child, Adolescent & Family is designed for the advanced second year student who is committed to improving the lives of children adolescents through psychosocial interventions. A major focus is to help students build a framework for social work interventions using normative developmental supports and case planning. Another focus is to prepare students to understand developmental stresses, disruption and challenges and to identify research informed social work interventions that include individual children, their caregivers and community settings that provide primary and supportive school, community, behavioral and mental health services.

☐Undecided

09/15 ww