Section 1: General Information and Fee Information

Transcription

1 APPLICATION AND EXAMINATION PROCESS INFORMATION LICENSED SOCIAL WORKER (LSW) LICENSED GRADUATE SOCIAL WORKER (LGSW) LICENSED INDEPENDENT SOCIAL WORKER (LISW) Authorized Practice: You may not practice social work in Minnesota without a license, unless (a) you are practicing social work in a setting for which licensure is not required pursuant to Minnesota Statutes, Sections 148E.065 or (b) you are issued a temporary license, pursuant to Minnesota Statutes, Sections 148E.060. Applying for licensure or passing the examination does not authorize you to practice before the effective date of your license. Section 1: General Information and Fee Information Review the Board s Statute, Chapter 148E (available at All Board and licensing requirements are found in the Board s statute, including 1) licensing and scope of practice, 2) instructions to apply for licensure, 3) temporary license requirements and fees, 4) supervised practice requirements, 5) standards of practice and ethical conduct, 6) endorsement requirements, and 7) license renewal requirements. One Year Application Time Limit: All requirements must be met within one year of the date the Board receives an application or the application will be closed. Plan accordingly to allow adequate time for each step of the process. Void Applications: Applications will be void and will be returned if 1) incomplete, 2) the Criminal Background Check form is required and is not submitted, or 3) an incorrect or no fee amount is submitted. Submit only the correct application fee, as noted below, with your application. Application Form and Criminal Background Check: All applicants must submit a completed application for licensure form and submit it with the correct application fee, as noted in the table below. If you have submitted a background check form with a previous licensure application, you are not required to resubmit the form or the $15 background check fee. The background check is required only once. Application Fees: Below are the application and background check fees. This is the only fee that you will submit with your application. You will pay a prorated initial license fee only after completing all requirements and upon written notification from the Board. For more information on fees, see the Board s website. All fees are nonrefundable. License Application Fee Endorsement Application Fee LSW $60 ($45 without BCA check fee) $100 ($85 without BCA check fee) LGSW $60 ($45 without BCA check fee) $100 ($85 without BCA check fee) LISW $60 ($45 without BCA check fee) $100 ($85 without BCA check fee) 1

2 Section 2: Documents Required When Submitting an Application for Licensure Never Licensed as a Social Worker in Minnesota, Or Any Other State Or Jurisdiction: Application and application fee Criminal Background check form and fee Official, complete transcript sent directly from college/university registrar (see below for details) Supervision Verification form (only if applying for LISW) Americans with Disabilities Act (ADA) and/or English as a Second Language (ESL) form (only if special provisions are needed for examination) Previously Licensed - Not Currently Licensed in Minnesota or Previously Applied - Never Issued a License in Minnesota: Application and application fee Criminal Background check form and fee (if not submitted previously) Official, complete transcript sent directly from college/university registrar (see below for details) Supervision Verification form (only if applying for LISW and not already submitted) Americans with Disabilities Act (ADA) and/or English as a Second Language (ESL) form (only if special provisions are needed for examination) Currently Licensed In Minnesota and Applying For a Different License: Application and application fee Official, complete transcript sent directly from college/university registrar (see below for details) Supervision Verification form (only if applying for LISW and not already submitted) Americans with Disabilities Act (ADA) and/or English as a Second Language (ESL) form (only if special provisions are needed for examination) Endorsement - Currently Licensed as a Social Worker in Another State: Application and application fee Criminal Background check form and fee Official, complete transcript sent directly from college/university registrar (see below for details) Verification of current license form Official Score Transfer Report from ASWB (if already taken ASWB examination) Supervision Verification form (only if applying for LISW) Americans with Disabilities Act (ADA) and/or English as a Second Language (ESL) form (only if special provisions are needed for examination) Official Transcript: All applicants applying for permanent licensure, including endorsement applicants, must request an official transcript submitted directly from their school s Registrar. It is not required if already on file with the Board. Supervision Verification Form: Complete and submit a Supervision Verification Form only if you are applying for an LISW license. It is not required if you are applying for an LSW or LGSW license. If you are currently licensed with the Board, any Supervision Verification Forms previously submitted will be automatically referenced. It is only necessary to document supervised practice not yet reported. Verification of License Form for Endorsement Applicants Only: If you apply through endorsement, please request the state(s) in which you are currently licensed to provide an official verification of licensure. A copy of your license credential is not sufficient. You may download this form from the Board s website. It is also included with the application materials. Americans with Disabilities Act (ADA) and English as a Second Language (ESL): The Board and the Association of Social Work Boards (ASWB) offer special examination provisions for persons with disabilities and persons who speak English as their second language. If either applies to you, forms may be downloaded from the Board s website. They are also included with the application materials. Refer to the instructions on the applicable forms. 2

3 Section 3: Application and Examination Process Board Notification of Application Status: The Board will notify you within 45 days indicating that either 1) your application materials are complete and you have been approved to take the examination, or 2) additional documentation is needed, in which case the Board will send you written notification. ASWB Licensure Examination: Examination approval: The Board will send written approval to all applicants required to take the Association of Social Work Boards (ASWB) exam that will allow you to register for the exam. You will pay the examination fee of $230 for the bachelors and masters exam, or $260 for the advanced generalist exam, directly to ASWB. If you wish to order a Study Guide, you may contact ASWB at or (800) Examination results: The Board receives examination results for both passing and failing scores from ASWB approximately two weeks after your examination date. The Board will then notify you if either additional documentation is needed or that you have been approved for licensure. If you were unable to obtain a passing score, the Board will send you a letter with further instructions regarding your options for rescheduling an examination with ASWB. Please note: At minimum, you will have to wait 90 days to re-register for the Association of Social Work Boards (ASWB) exam. You will need to re-submit another license application and the $45 application fee to the Board if you do not meet all license application requirements within your oneyear application deadline. Endorsement Applicants: If you have taken the required ASWB licensure examination, contact ASWB directly at or (800) and request that an Official Score Transfer Report is mailed directly to the Board. Board Notification of Approval for Licensure: The Board will send written notification to inform you that you have been approved for licensure when all requirements have been completed. You will pay a prorated initial license fee at this time, and your license is effective the date the fee is received. Initial license fees submitted on or after July 1, 2010 through June 30, 2015 will also be assessed the mandatory Office of Enterprise Technology (OET) Surcharge of 10% of the prorated initial license fee, or a minimum of $5, whichever is greater. The OET will establish a statewide one stop electronic licensing system with the money collected. [See Minnesota Statutes, section 16E.22] Section 4: Temporary License Information Temporary License Information: (Refer to Minnesota Statutes, Section 148E.060) A temporary license is optional and authorizes practice while an application for a permanent license is being processed. If you meet the requirements listed below, contact the Board office at social.work@state.mn.us to obtain forms or information. There is a separate $50.00 fee for a temporary license, which is only submitted with the Temporary License Application form. There are three provisions for temporary licenses as highlighted below: Students or persons not currently licensed in another jurisdiction who have applied for a permanent license and: a) have passed the ASWB national licensure examination and b) have completed all degree requirements, or Emergency situations or social workers currently licensed in another jurisdiction with or without having applied for a permanent license who: a) have completed all degree requirements and b) have submitted evidence satisfactory to the Board verifying current licensure, or Teachers, whose permanent residence is outside the United States, and teach social work in Minnesota, not to exceed 12 months, or Applicants whose social work programs are in candidacy status with CSWE or a similar accrediting body who have applied for a permanent license: a) have passed the ASWB national examination b) have completed all degree requirements. In compliance with the Americans with Disabilities Act, this instruction sheet and all enclosed materials may be made available in alternative formats upon request. K:\Sharedoc\FORMS\Forms 2012\SWAP Instructions Paper applications doc 3

4 APPLICATION FOR LICENSURE APPLICANT STATUS (please type or print clearly with black ink) I AM APPLYING FOR LICENSURE AT THE FOLLOWING LEVEL (check one): ~ Licensed Social Worker (LSW) ~ Licensed Graduate Social Worker (LGSW) ~ Licensed Independent Social Worker (LISW) MY CURRENT LICENSURE STATUS IS (check one): ~ Never licensed as a social worker in Minnesota or any other state or jurisdiction ~ Previously but not currently licensed as a social worker in Minnesota ~ Currently licensed in Minnesota and applying for a different level of licensure ~ Currently licensed as a social worker in another state or jurisdiction and applying through endorsement APPLICANT DATA You MUST provide the following data: 1) Full legal name: If you make changes in your legal and/or professional name, you may be contacted by the Board if additional information is needed. 2) Professional name (if applicable): You may practice under a professional name that may be different from your legal name provided that you inform the Board of both the professional and legal name. 3) Mailing address: Your mailing address is classified as public. All information from the Board will be sent to your mailing address. The telephone number that you provide with your mailing address is also public. 4) Home address: If your home address is different from your mailing address, your home address is classified as private and cannot be accessed by the public. Classification of Data: All information provided is private until your application has been approved. Once it has been approved, all information is public except as noted in the application. Public information is available to any person upon request. The purpose and intended use of this information is to determine whether you meet legal requirements for licensure. You are not required to provide the information requested on this form, but the Board will not be able to act on your application without this information. LICENSE NUMBER: (if applicable) SOCIAL SECURITY NUMBER: (required, but private) CURRENT LICENSE: (if applicable, circle one) LSW LGSW LISW LICSW FULL LEGAL NAME: LAST NAME FIRST NAME: MIDDLE NAME: PROFESSIONAL NAME: LAST NAME (IF DIFFERENT) ALL MAIDEN, ALIAS, AND/OR FORMER NAMES: FIRST NAME: MIDDLE NAME: HOME ADDRESS: (NEW? YES NO ): CITY: COUNTY: STATE: ZIP CODE: TELEPHONE HOME: TELEPHONE BUSINESS: FAX: MAILING ADDRESS (if different from home address): (NEW? YES NO ): CITY: COUNTY: STATE: ZIP CODE: DAYTIME PUBLIC TELEPHONE: DATE OF BIRTH (mm/dd/yyyy): (optional) ETHNIC BACKGROUND(circle): (optional) GENDER (circle): MALE FEMALE (optional) African American Asian/Pacific Islander Hispanic Other Caucasian Native American/Alaskan Native Multi-Racial 1

5 EDUCATIONAL INFORMATION UNDERGRADUATE PROGRAM GRADUATE PROGRAM INSTITUTION NAME: INSTITUTION NAME: LOCATION: LOCATION: DEGREE: MAJOR: DEGREE: MAJOR: DATE DEGREE CONFERRED OR ANTICIPATED (month/year): DATE DEGREE CONFERRED OR ANTICIPATED (month/year): CURRENT EMPLOYMENT INFORMATION Record all current employment information. If currently unemployed, indicate "unemployed" on line 1. If you have more than two current employers, please list the additional employers on a separate sheet of paper including the same information as requested below and attach. CURRENT EMPLOYER #1: (no acronyms) ADDRESS: TELEPHONE: FAX: CITY: COUNTY: STATE: ZIP CODE: TITLE OF (noacronyms) YOUR POSITION: SUPERVISOR'S NAME: DATES OF EMPLOYMENT: FROM (mo/yr) TO (mo/yr) MN BUSINESS ID#: (Required only if one has been issued by the MN Dept of Revenue) CURRENT EMPLOYER #2: (no acronyms) ADDRESS: TELEPHONE: FAX: CITY: COUNTY: STATE: ZIP CODE: TITLE OF (no acronyms) YOUR POSITION: SUPERVISOR'S NAME: DATES OF EMPLOYMENT: FROM (mo/yr) TO (mo/yr) MN BUSINESS ID#: (Required only if one has been issued by the MN Dept of Revenue) LIST OF SUPERVISORS Applicants for the LISW license only: Please list the names of the supervisors who are submitting Supervision Verification Forms on your behalf as part of this application process. If you are currently licensed in Minnesota, DO NOT list forms that have been previously submitted and considered by the Board. Previously submitted forms will automatically be considered. SUPERVISOR #1: SUPERVISOR #2: SUPERVISOR #3: 2

6 STANDARDS OF PRACTICE QUESTIONS Please do the following: Answer all questions by checking the appropriate box. Provide a complete explanation of any yes answers. For any yes answers, include a copy of any relevant records of court or licensing agency actions. Attach additional sheets if necessary to provide sufficient detail. Your answers, including any written materials you submit, will be public data and available to the public upon request after you are licensed, except as noted in question 11 and except for any data collected by the board in investigating the information you submit. NOTE: In the questions below, licensing means licensing, registration, credentialing, certification, or any other form of government regulation of individual practitioners. If you are currently licensed by the Board, do not report information you have already reported on an application for license renewal unless there is new information not previously reported. YES NO 1. Have you ever pled guilty to, pled no contest to, or been convicted of a misdemeanor, gross misdemeanor, or felony, or are criminal charges pending against you? Include traffic offenses where the charge involves the use of alcohol or drugs even if the final conviction or plea is not related to the use of alcohol or drugs. If Yes: Please explain in detail and provide the appropriate documents. YES NO 2. Have you ever been disciplined, sanctioned, or been found to have violated a professional association s code of ethics or a state, territorial, provincial, or foreign licensing agency s laws or rules, are you currently under investigation by such an association or agency, or have you ever been investigated by such an association or agency? If Yes: Please explain in detail and provide the appropriate documents YES NO 3. Have you ever violated any state, territorial, provincial, or foreign licensing agency s law or rule related to the practice of social work or any other profession not addressed in question 2 or are any proceedings pending against you? If Yes: Please explain in detail and provide the appropriate documents. YES NO 4. Have you ever relinquished your membership in a professional association or your license from a state, territorial, provincial, or foreign licensing agency while a complaint was pending against you? If Yes: Please explain in detail and provide the appropriate documents. YES NO 5. Have you ever applied for and been denied (a) membership in a professional association, or (b) licensure by a state, territorial, provincial, or foreign licensing agency or are any proceedings pending against you? If Yes: Please explain in detail and provide the appropriate documents. YES NO 6. Have you ever, in order to avoid denial, withdrawn an application for (a) membership in a professional association, or (b) licensure by a state, territorial, provincial, or foreign licensing agency? If Yes: Please explain in detail and provide the appropriate documents. YES NO 7. In any paid or volunteer job you have held, have you ever been terminated, had a contract not renewed, been subjected to disciplinary action of any kind, or resigned in lieu of termination or disciplinary action or are any employment proceedings pending against you? If Yes: Please explain in detail and provide the appropriate documents. YES NO 8. Are you now or have you ever been a party to civil litigation, arbitration, mediation, or a malpractice action related to any paid or volunteer job you have held? If Yes: Please describe the allegations, responses, and your role in the incident. Also provide the appropriate documents. YES NO 9. Have you ever (a) engaged in, or assisted an individual to engage in, the practice of social work without a license in a non-exempt setting, or (b) falsely used, or assisted an individual to falsely use, the title social worker? If Yes: Please explain in detail and provide the appropriate documents. YES NO 10. Have you ever been subjected to disciplinary action by a post-secondary educational institution, withdrawn from a post-secondary educational institution or been investigated by a post-secondary educational institution, because of alleged misconduct of any kind? If Yes: Please explain in detail and provide the appropriate documents. 3

7 YES NO 11. Are you currently unable to practice with reasonable skill and safety by reason of illness, use of alcohol, drugs, chemicals, or any other materials, or as a result of any mental, physical, or psychological condition? If Yes: Please explain in detail and provide the appropriate documents. This information will remain confidential under all circumstances. VERIFICATION OF LICENSE (Endorsement applicants only) Endorsement Applicants Only: You must provide a license verification ONLY fron the jurisdictions(s) in which you are currently licensed as a social worker. For the purpose of this section, license includes licensing, registratoin, credentialing, certification, or any other form of government regulation of individual practitioners. Provide the following information regarding each license/credential. State or Other Jurisdiction License Number Type / Level of License Date License Issued Expiration Date of License License Obtained By* *Indicate if by Examination, Grandparenting, Endorsement, Reciprocity or Other (specify) NOTE: You must have the licensing/credentialing agency listed above submit verification of your license directly to the Minnesota Board of Social Work, using the Verification of Licensure form included in this packet. TEMPORARY LICENSE INFORMATION (Complete only if you would like information and an application form mailed to you.) NOTE: An applicant who is practicing social work in Minnesota at the time of application, in a setting for which licensure is required, is ineligible for a temporary license. (Minnesota Statutes, Sections 148E.06.) NOTE: All fees submitted to the Board are non-refundable. DO NOT SEND THE TEMPORARY LICENSE FEE WITH THIS APPLICATION. A temporary license is time-limited and nonrenewable, or until issuance or denial of a permanent license, or until revocation of the temporary license, whichever occurs first. A temporary license fee is $ Temporary license holders not licensed in another jurisdiction at all levels of authorized practice must obtain appropriate supervision for social work practice in Minnesota, and must submit documentation to the Minnesota Board of Social Work verifying that supervision. Temporary licenses may be granted to applicants who meet the following requirements: 1) students and persons not currently licensed in another jurisdiction who have applied for a permanent license if you (a) have passed the ASWB national licensure examination, (b) have completed all degree requirements, OR 2) social workers licensed in another jurisdiction, applying for a permanent license, OR emergency Minnesota practice situations without having applied for permanent, if you (a) have completed all degree requirements, and (b) have submitted evidence satisfactory to the Board verifying your current license. OR 3) teachers whose permanent residence is outside of the United States, teaching social work in an academic institution in Minnesota for a period not to exceed 12 months. I understand that by checking the appropriate box below a Temporary License Application form will be sent to my designated mailing address when my Application for Licensure form is received by the Board office. (See the Board s website ). (Check applicable category.) DO NOT SEND THE TEMPORARY LICENSE FEE WITH THIS APPLICATION. ~ APPLICANT FOR TEMPORARY LICENSE- NOT CURRENTLY LICENSED IN ANY OTHER JURISDICTION ~ ~ APPLICANT FOR TEMPORARY LICENSE- TEACHER WITH PERMANENT RESIDENCE APPLICANT FOR TEMPORARY LICENSE- CURRENTLY LICENSED IN ANOTHER JURISDICTION 4

8 CERTIFICATION OF APPLICANT (all applicants must complete this section) 1. By signing and dating below I certify that I understand that I am obligated to comply with and keep informed of changes to the Board s statute and other regulations governing social work practice. I have read the Board s statute, Chapter 148E (available at governing social work practice in Minnesota. 2. I certify that all information provided in this application is true and correct to the best of my knowledge. I understand that making a false statement or misrepresentation to the Board is grounds for the Board to take disciplinary action against my license. 3. I agree upon licensure to comply with all ongoing licensure requirements, including the standards of practice, supervised practice (if applicable), and license renewal requirements. 4. I will not practice social work in Minnesota without a license, unless (a) I am practicing social work in a setting for which licensure is not required pursuant to Minnesota Statutes, Sections 148E.065 or (b) I am issued a temporary license, pursuant to Minnesota Statutes, Sections 148E.060. Applying for licensure or passing the examination does not authorize me to practice before the effective date of my license. 5. I understand that submission of this application does not automatically result in approval of my application. If all requirements are satisfied, or if additional information is needed, the Board will contact me. 6. Address Change: I understand that I must notify the Board within 30 days of any changes in my mailing address, home address, or telephone number. I understand I must submit this change via US mail, , fax, or the Board s website. 7. Name Change: I understand I must notify the Board of any changes to my legal or professional name within 30 days of the change by US mail. I understand there is a form available on the Board s website that must be completed and submitted, with the applicable documentation and fee, to the Board office. SIGNATURE OF APPLICANT: DATE: FEES Below is a list of application fees. This is the only fee that you will submit with your application. Exception: If you have submitted a criminal background check form with a previous application, you are not required to resubmit the form or the $15 background check fee. The background check is required only once. Application Type Never licensed as a social worker in Minnesota or any other state or jurisdiction Currently licensed in Minnesota and applying for a different license Previously, but not currently, licensed as a social worker in Minnesota Including Background Check Fee Without Background Check Fee (see above for exception) $60 $45 N/A $45 $60 $45 Currently licensed as a social worker in another state or $100 $85 jurisdiction and applying through endorsement VOID APPLICATION: Applications that are incomplete or not accompanied by the correct fee are void and will be returned to you. K:\Sharedoc\FORMS\Forms 2011\Application for Licensure LSW LGSW LISW 2011.wpd 5

9 CRIMINAL BACKGROUND CHECK FOR APPLICANTS USE THIS FORM ONLY IF SUBMITTING WITH A PAPER APPLICATION ONE TIME REQUIREMENT: The Board s Statute, Chapter 148E.055, Subdivision 2,3,4, and 5, requires that all applicants for social work licensure complete a criminal background check with the Minnesota Bureau of Criminal Apprehension (BCA). The Minnesota Board of Social Work will forward this form to the Minnesota Bureau of Criminal Apprehension. If you have submitted a background check form with a previous application, you are not required to resubmit the form or the $15 background check fee. The background check is required only once. FEE: The required $15.00 fee is assessed by the BCA to conduct the criminal background check. This fee is forwarded to the BCA when the criminal background check has been completed. This fee may be included with your application fee in one personal check, cashier s check or money order, made payable to the Minnesota Board of Social Work. DATA CLASSIFICATION: Any criminal history reported to the Board will be public data and available to the public upon request after you are licensed, except for any data collected by the Board in investigating the information you submit. INSTRUCTIONS: 1) Please type or clearly print all data. 2) Provide your signature and date. 3) Submit to the Board office with the correct fee. (FULL LEGAL NAME) LAST NAME: APPLICANT DATA FIRST NAME: MIDDLE NAME (full): ALL MAIDEN, ALIAS AND/OR FORMER NAMES: SOCIAL SECURITY NUMBER: (private data) DATE OF BIRTH (mm/dd/yyyy): SEX (M OR F): I authorize the Minnesota Bureau of Criminal Apprehension to disclose criminal history record information to the Minnesota Board of Social Work, as required by Minnesota Statutes148E.055, subdivision 2, 3, 4, and 5. This authorization expires one year from the date of my signature. SIGNATURE OF APPLICANT: DATE: K:\Sharedoc\FORMS\Forms 2011\BCA Applicant Form 2011 Paper.docx

10 NONCLINICAL SUPERVISION VERIFICATION For LSW and LGSW (Revised August 1, 2012) INSTRUCTIONS TO COMPLETE THIS FORM PLEASE TYPE OR PRINT CLEARLY IN BLACK INK AND KEEP ALL PAGES OF THIS FORM TOGETHER. 1. Each of your supervisor(s) must complete and submit a separate form. This form may be duplicated. 2. Attach a job description to this form, which corresponds to the position being documented, if not previously submitted. 3. Complete page 1. Then submit the entire form to your supervisor for completion of pages 2 and 3. Your supervisor must submit all pages of this form directly to the Board. Please Note: This form will be reviewed at time of renewal or when applying for a different license. LICENSEE/APPLICANT INFORMATION (Applicant/licensee must complete this section.) CIRCLE THE APPLICATION FORM THAT YOU ARE SUBMITTING WITH THIS SUPERVISION VERIFICATION FORM: LICENSURE APPLICATION LICENSURE RENEWAL NOT SUBMITTED WITH AN APPLICATION or RENEWAL HAVE YOU PREVIOUSLY SUBMITTED A SUPERVISION PLAN FOR THE SUPERVISED PRACTICE REPORTED ON THIS FORM? (circle) YES NO LICENSE NUMBER: CURRENT LICENSE HELD: (circle) LSW LGSW non-clinical scope LAST NAME: (as it appears on license card) FIRST NAME: MIDDLE NAME: MAILING ADDRESS: (NEW? circle: YES NO) ADDRESS: CITY: COUNTY: STATE: ZIP CODE: DAYTIME PUBLIC TELEPHONE: FAX: LICENSEE/APPLICANT POSITION INFORMATION SUBMITTED AGENCY/EMPLOYER NAME FOR POSITION REPORTED ON THIS FORM (may be different from current employment): AGENCY ADDRESS: CITY: COUNTY: STATE: ZIP CODE: LICENSEE/APPLICANT S POSITION TITLE: RECORD FULL-TIME & PART-TIME PRACTICE DATES & NUMBER OF PART-TIME HOURS PER WEEK FOR THE POSITION REPORTED FULL-TIME FROM: (mo/yr) TO: (mo/yr) PART-TIME FROM: (mo/yr) TO: (mo/yr) NUMBER OF HOURS PER WEEK: 1

11 SUPERVISOR SECTION INSTRUCTIONS FOR SUPERVISOR PLEASE TYPE OR PRINT CLEARLY IN BLACK INK AND KEEP ALL PAGES OF THIS FORM TOGETHER. All Supervisors: 1. Complete pages 2 and Review the attached position description, if applicable. 3. Submit all pages of this form directly to the Board office at the address listed on the form. SUPERVISOR INFORMATION (Supervisor must complete this section.) LAST NAME: FIRST NAME: MIDDLE NAME: MAILING ADDRESS: CITY: STATE: ZIP CODE: HIGHEST DEGREE: MAJOR: DATE DEGREE CONFERRED: COLLEGE OR UNIVERSITY: SOCIAL WORK LICENSE NUMBER: OTHER BOARD LICENSE NUMBER:: (attach copy of current license if not submitted with Supervision Plan) PRESENT EMPLOYER: LICENSE HELD: STATE:(if other than MN, attach copy of current license if not submitted with Supervision Plan) EFFECTIVE DATE OF LICENSE: LICENSE HELD: STATE: EFFECTIVE DATE OF LICENSE: TITLE AT TIME OF SUPERVISION: ADDRESS: SUPERVISOR CITY: STATE: ZIP CODE DAYTIME PUBLIC TELEPHONE: SUPERVISOR S REPORT OF SUPERVISION PROVIDED PRIOR TO AUGUST 1, 2011 Dates of Supervision: FROM: (mo/yr) TO: (mo/yr) For the dates listed above, list average number of hours per month for each type of supervision provided below: In-person one-on-one supervision: In-person group supervision: Electronic supervision: Number in group, excluding supervisor(s): NOTE: At least ½ of the supervision must be in-person one-on-one supervision. In-person group supervision may not exceed more than ½ of the required hours. Electronic supervision may not exceed more than 1/3 of the required hours. Group supervision may not exceed 7 members, including licensed social work supervisor. SUPERVISOR S REPORT OF SUPERVISION PROVIDED ON OR AFTER AUGUST 1, 2011 Dates of Supervision: FROM: (mo/yr) TO: (mo/yr) For the dates listed above, list average number of hours per month for each type of supervision provided below: Mandatory One-on-One Supervision Hours Other Types of Supervision Permitted (50% required) (no more than 50% allowed) In-Person hrs/mo (minimum 25%) One-on-One telephone hrs/mo Eye-to-Eye electronic media hrs/mo Group hrs/mo Number in group, excluding supervisor(s) NOTE: Group supervision is limited to six supervisees and may include in-person, telephone, or eye-to-eye electronic media. Supervision must not be provided by . LICENSEE/APPLICANT NAME & LICENSE NUMBER: 2

12 RECOMMENDATION/CERTIFICATION BY THE SUPERVISOR (Supervisor must complete this section by circling response.) Yes No (If applicable) I am a supervisor licensed as a social worker in Minnesota. I have completed a one-time requirement of 30 hours of training in supervision and understand this information will be available to the public at the Board s website. Yes No (If applicable) I am an alternate supervisor, and I am a currently licensed mental health professional qualified to provide supervision according to my licensing board. Yes No If you signed a Supervision Plan for the licensee/applicant, do you affirm that the supervision provided for the position documented within this form was carried out as described previously in the Supervision Plan considered and approved by the Board? Yes No Is the position description which the licensee/applicant has attached (if applicable) to this form an accurate reflection of the licensee/applicant s practice? If not, please attach an explanation. Yes No Do you attest that the supervisee has not engaged in conduct in violation of the Standards of Practice specified in the Board s Statute, Chapter 148E.195 to 148E.240? Yes No Do you attest that the supervisee has practiced competently and ethically in accordance with professional social work knowledge, skills, and values? If not, please attach an explanation. Yes Yes Yes Yes Yes No No No No No Do you affirm that the content of the supervision has included: 1. development of professional social work knowledge, skills, and values 2. practice methods 3. authorized scope of practice 4. ensuring continuing competence 5. ethical standards of practice Affirmation: I hereby affirm that I directly supervised the named licensee/applicant and affirm that the supervisee has met the applicable supervised practice requirements. I also affirm that the information I have provided is true and correct to the best of my knowledge. I understand that this information will be used to evaluate the supervisee s compliance with requirements for licensure as a social worker. SUPERVISOR NAME: (please print) SUPERVISOR SIGNATURE: LICENSE HELD & LICENSE NUMBER: DATE: Classification of Data: Information which you and your supervisor provide on this form is classified as private data prior to licensure and is accessible only to you, Board members and staff, the Board's legal counsel, and persons whom you designate. When your application is approved, the information provided on this form and all other information related to your supervision verification will be classified as public data. Public data is available to any person upon request. The purpose and intended use of this information is to enable the Board to determine whether the documented supervised practice meets statutory requirements for licensure. You are not legally required to provide this information, but the Board will not be able to take action without this information. SUPERVISOR: PLEASE RETURN THE ORIGINAL FORM DIRECTLY TO THE BOARD OFFICE ADDRESS LISTED ON THE TOP OF THE FIRST PAGE. PLEASE MAKE A COPY OF THIS FORM FOR YOUR RECORDS. LICENSEE/APPLICANT NAME & LICENSE NUMBER: K:\Sharedoc\FORMS\Forms 2012\LSW AND LGSW NONCLINICAL SUPERVISION VERIFICATION 2012.docx 3

13 AMERICANS WITH DISABILITIES ACT (ADA) REFERENCE SHEET General Information If you are a person with a disability, you have certain rights under the Americans with Disabilities Act (ADA). If you have any questions about your rights under the ADA we encourage you to call the United States Department of Justice, which has an ADA Information Line, at (202) (voice) or (202) /0383 (TDD). These telephone numbers are not toll-free numbers. About the Examination The Board of Social Work utilizes a national licensure examination provided by the Association of Social Work Boards (ASWB). The examination is a multiple-choice examination. Candidates are permitted four hours to take the examination. The examination is administered by Pearson VUE. The test is presented on a personal computer. No computer experience is needed to take the examination, and you will receive a brief tutorial to help you become familiar with the testing equipment. All Pearson VUE testing sites are accessible to persons with physical disabilities. Alternative Arrangements The ADA requires the Board of Social Work, ASWB, and testing sites to make "reasonable accommodations" for applicants with disabilities taking this examination. If you are a person with a disability, which may affect your ability to enter the examination facility or take any portion of the examination, the ADA may require the Board of Social Work, ASWB, and the testing site to provide certain accommodations. We are not required to provide accommodations if we are unaware of your needs. You will be notified by letter whether your accommodation has been granted. INSTRUCTIONS If you have a disability for which you need examination accommodations, please use the attached APPLICATION FOR DISABILITY ACCOMMODATION form. 1. Please complete Part I. 2. Your health care practitioner must complete Part II. 3. You must mail both the completed Part I and Part II of the Application for Disability Accommodations Form directly to ASWB, who will coordinate the processing of your request with the Minnesota Board of Social Work. NOTE: A completed Application for Disability Accommodations Form will remain valid for one year from the date when executed by the applicant. Forms not fully completed will be returned to the applicant. 1

14 INSTRUCTIONS APPLICATION FOR DISABILITY ACCOMMODATIONS ASSOCIATION OF SOCIAL WORK BOARDS The Application for Disability Accommodations is to help the social work board in your jurisdiction determine (1) whether you are a qualified disabled individual under applicable federal, state, provincial, or local legislation and (2) whether the accommodation you are requesting is reasonable. Consideration of all requests will be made under applicable laws. PART I: The information requested on Part I of the form is self-explanatory. You are required to furnish your Social Security Number, but this information would be most helpful in identifying you and relating this Application for Disability Accommodations to other parts of your examination application. After you have completed Part I, the application must be dated and signed by you and notarized by a Notary Public in your jurisdiction. ALL APPLICATIONS MUST BE SUBMITTED WITH ORIGINAL SIGNATURES. COPIES OR FAXED SIGNATURES WILL NOT BE ACCEPTED. PART II: Part II of this Application for Disability Accommodations should be completed by your health care practitioner or other appropriate professional and signed and dated where indicated. ALL APPLICATIONS MUST BE SUBMITTED WITH ORIGINAL SIGNATURES. COPIES OR FAXED SIGNATURES WILL NOT BE ACCEPTED. SUBMISSION OF THE FORM: The ASWB examinations are offered through the relevant jurisdictional board. Although each board s application process may differ slightly, this form must be submitted before the board can make a decision on any examination accommodations requested. Parts I and II of this Application for Disability Accommodations should be mailed directly to ASWB at the address below. You must receive approval from your board and ASWB before registering for an examination. Forms not fully completed will be returned to the applicant. Please consult with your board to determine the appropriate application process and relevant deadlines. A submitted Application for Disability Accommodations will remain valid for one year from the date when executed by the applicant. A valid application will be considered for any examination within this one-year period provided the applicant makes a request at the time of registration. Under any circumstances, it is recommended that you maintain a copy of this form for your records. Questions may be directed to your board or to ASWB ( , extension 3003). SUBMIT PARTS I AND II OF THE APPLICATION FOR DISABILITY ACCOMMODATIONS AT THE SAME TIME TO ASWB Applications for Disability Accommodations should be mailed to: ASWB Candidate Registration Center P.O. Box 1508 Culpeper, VA K:\Sharedoc\FORMS\Forms 2011\ADA Reference Sheet and Instructions 2011.doc 2

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17 English as a Second Language Special Arrangements Request Where credentialing boards in individual jurisdictions permit, qualified candidates for social work licensure who use English as a Second Language (ESL) may request additional time (up to two extra hours) and the use of up to two dictionaries (one bilingual and/or one standard English). Where applicable, requests will be forwarded to the appropriate credentialing board for approval. ASWB reserves the right to have the candidate bear the expense of the dictionary under some conditions. The association also reserves the right to modify this policy. To apply, please fill in the following information: Name: Address: Social Security Number (US)/Social Insurance Number (Canada): Date of Birth: Month Day Year Your primary (first) language: Work phone: Home phone: Cell phone: State/Province/Territory to which you are applying: DISTRICT OF COLUMBIA CANDIDATES ONLY: If you attended a college or university in the United States, you will not be eligible for special arrangements in DC. In what country did you attend college? UTAH CANDIDATES PLEASE NOTE: Utah law allows additional time ONLY; dictionaries are not permitted.* Special Testing Arrangements Requested Extra time: (Please check one box.) None 1 hour 1.5 hours 2 hours Dictionary(ies): (You may select up to two dictionaries.) *Not Permitted in UT None English English/Spanish Other - English/ (Please indicate foreign language here.) Under penalties of perjury, I declare that the foregoing statements are true. I understand that false information may be cause for denial or loss of a license. I hereby certify that I personally completed this application and that I may be asked to verify the above information at any time. Signature Date Subscribed to and sworn before me this day of Notary Public Please consult with your credentialing board to determine the appropriate application process. It is recommended that you retain a copy of this form for your records. Questions may be directed to your board or to ASWB ( , extension 3003). Approved requests shall be valid indefinitely for the approving jurisdiction unless revoked by that credentialing board or ASWB. Mail your completed form to: ASWB Candidate Registration Center, P.O. Box 1508, Culpeper, VA Version 5/2/2012

18 VERIFICATION OF LICENSE GENERAL INFORMATION Endorsement Applicants Only: You must provide a license verification ONLY from the jurisdiction(s) in which you are currently licensed as a social worker. Please complete and submit this form to the appropriate licensing/credentialing agency and have that agency submit the form directly to the Minnesota Board of Social Work. All information provided is private until your application has been approved. Once it has been approved, all information is public except as noted in the application. Public information is available to any person upon request. The purpose and intended use of this information is to determine whether you meet legal requirements for licensure. You are not required to provide the information requested on this form, but the Board will not be able to act on your application without this information. Endorsement Applicants & ASWB Score Transfer Report: If you are an applicant with Minnesota by Endorsement and if you have taken the applicable level ASWB examination, you must also contact ASWB at (800) and request that an Official Score Transfer Report be sent directly to the Minnesota Board of Social Work. INSTRUCTIONS TO APPLICANT Please provide all information requested on page 1 of the Verification of Licensure form. Send a copy of this complete form (pages 1 and 2) to each licensing/credentialing agency from which you have ever received a professional license or credential. (Be sure to enclose any fee that agency may require.) Instruct the licensing/credentialing agency to complete page 2 of this form and return it directly to the Board office. LICENSE NUMBER: TO BE COMPLETED BY APPLICANT SOCIAL SECURITY NUMBER: (private data) DATE OF BIRTH: (MM/DD/YYYY) LAST NAME: FIRST NAME: MIDDLE NAME (full): ALL MAIDEN, ALIAS, AND/OR FORMER NAMES: MAILING ADDRESS: TELEPHONE HOME: (include area code) BUSINESS: I hereby authorize the state licensing/credentialing agency named on the reverse side to release information contained in my file directly to the Minnesota Board of Social Work. SIGNATURE: DATE: Reverse side to be completed by Licensing/Credentialing Agency

19 TO BE COMPLETED BY STATE LICENSING/CREDENTIALING AGENCY The individual listed on the reverse side of this form has applied for a social work license from the Minnesota Board of Social Work. Before further consideration can be given, the Board requires the information requested below. Please provide all information and return this form directly to the Board office at the address listed below. STATE OF: DATE INITIAL LICENSE/CREDENTIAL ISSUED: LEVEL OR TITLE OF LICENSE/CREDENTIAL: TYPE OF LICENSE/CREDENTIAL (circle): PERMANENT TEMPORARY OTHER STATUS OF LICENSE/CREDENTIAL (circle): ACTIVE/CURRENT OTHER: INACTIVE EMERITUS EXPIRED EFFECTIVE DATE OF CURRENT STATUS: EXPIRATION DATE (if current): LICENSE/CREDENTIAL WAS OBTAINED BY (circle): GRANDPARENTING EXAMINATION RECIPROCITY ENDORSEMENT Has this individual s license/credential ever been revoked, suspended, conditioned, or otherwise encumbered for any reason? (circle) (If yes, please attach a letter explaining the details of this case and any other applicable documentation related to this case.) Are there any current complaints or pending investigations regarding this individual? (circle) (If yes, please attach a letter explaining the details of this case.) YES YES NO NO SIGNATURE OF PERSON COMPLETING FORM: DATE COMPLETED: NAME: (print) TITLE: NAME OF STATE LICENSING/CREDENTIALING AGENCY: TELEPHONE NUMBER: ATTENTION STATE LICENSING/CREDENTIALING AGENCY: Please affix your Board/State seal here Please complete and return this form directly to: MINNESOTA BOARD OF SOCIAL WORK 2829 UNIVERSITY AVE SE STE 340 MINNEAPOLIS MN K:\SHAREDOC\FORMS\FORMS 2008\VERIFICATION OF LICENSURE FORM 2008.DOC