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1 School Social Work Licensure: Clinical Experience Summary Report Provide your name and PSU ID and submit to the MSW Program Director. The program will complete Section 1 and will provide the date and initial review (name and role) for each assessment point. Submit the completed portfolio to the MSW Program Director for the final review. The approved report will be returned to you for submission to the PSU School of Education. Because the final review will likely occur after graduation from the MSW program, please provide an address where we can mail your completed report. STUDENT: PSU ID: ADDRESS: Section 1 Assessment Method Personal Statement (s) Completed Initial Reviewer Name Role (advisor, instructor, etc.) Final Review (Indicate if Satisfactory; Comments) Recommendation Ratings Applicant Experience (CONTINUE ON REVERSE SIDE)

2 Section 2 (Clinical Experience Summary Report page 2 of 2) Assessment Method Student Personal Assessment Questionnaire (PAQ) (s) Completed Generalist 1 Generalist 2 Initial Reviewer Name Role (advisor, instructor, etc.) Final Review (Indicate if Satisfactory; Comments) Advanced 1 Advanced 2 Field Evaluations Generalist Fall Generalist Win Generalist Spr Advanced Fall Advanced Win Advanced Spr Field Tracking Sheets School Community Portfolio PAQs Field Evals Synthesis Paper Resume Final Review completed by: Name and Position Signature

3 School Social Work License Course of Study and License Requirements Concentration: Practice and Leadership with Communities and Organizations (2-Year Full-time Option)* Dept NO Course CR SW 511** Field Placement and Seminar (Fall) 4 SW 511** Field Placement and Seminar (Winter) 4 SW 511** Field Placement and Seminar (Spring) 4 SW 530 Skills for helping Process- Individuals and Families 3 SW 515 Skills for helping Process- Groups 3 SW 532 Advocacy and Empowerment 3 SW 539 Social Justice in Social Work 3 SW 520 Social Welfare History and Policy 3 SW 540 Human Development Through the Life Span 3 SW 541 Societal, Community and Organizational Structures and 3 Processes. SW 550 SW 550 Research and Evaluation 3 SW 551 SW 551 Research and Evaluation II 3 SW 512** Advanced Field Placement (Fall) 4 SW 512** Advanced Field Placement (Winter) 4 SW 512** Advanced Field Placement (Spring) 4 SW 593 Practice and Leadership with Community Organizations 3 SW 594 Practice and Leadership with Community Organizations 3 SW 595 Practice and Leadership with Community Organizations 3 SW 564 Social Work in Schools 3 ELP 581 US and Oregon School Law and Policy 4 SW 588 Social Work with Children, Youth and Families 3 Choose 1 of the following Research Electives SW 510 Community and Organizational Research 3 SW 510 Racial Disparities: Analysis and Action 3 Choose 2 Additional Electives SW 5 Elective 3 SW 5 Elective 3 Additional Requirements SW Required Intent to enroll form submitted SW Required TSPC Fingerprinting and PA-1 form completed SW Required 15 hours of direct practice with Children 3-8 (see task sheet) SW Required 15 hours of direct practice with youth 9-14 (see task sheet) SW Required 15 hours of Direct Practice with youth (see task sheet) SW Required Portfolio *The Course of Study can easily be adjusted for students in the 3- and 4-year option. **Field Placements: One year must be in a school setting and one year must be in a community-based agency serving children, youth and families.

4 VERIFICATION OF SCHOOL SOCIAL WORK FIELD REQUIREMENTS Over the course of two field placements, students must complete AT LEAST 15 hours of direct practice with children who are (a) ages 3-8, (b) ages 9-14 and (c) ages This must include individual and group work within EACH age group. FIELD INSTRUCTION: School Setting MSW Field Instructor License (LCSW, LMSW, etc.): If Instructor is not licensed, submit the Field Instructor Waver form to TSPC through School of Social Work Field Office by first week in winter term. Form available on School Social Work Licensure website. Fall Term: Orientation to Agency Completed Initial Personal Assessment Questionnaire (PAQ) Completed Field Educational Plan (FEP) due by the 5 th week of the term Initiation of relationships (students, teachers, families, community partners, etc.). FEP can describe activities related to initiation of relationships Student Assessment (e.g. social/emotional) Weekly Supervision (attach Fall Timesheet) Fall Evaluation of Student Learning Winter Term: Outreach to and individual work with teachers, students, families (see FEP) Classroom Instruction (e.g. social skills training) Case management and community linkages School, LEA and Community Assessment Evaluation of Practice Weekly Supervision (attach Winter Timesheet) Winter Evaluation of Student Learning Submit Field Instructor Waver form (if applicable) Spring Term: Individual work and case management with planned termination Classroom Instruction (e.g. social skills training) Cross- level experience Macro Intervention Plan, Implementation and Assessment Evaluation of Practice Weekly Supervision (attach Spring Timesheet) Complete End- of- Year PAQ Spring Evaluation of Student Learning Student Signature Faculty Advisor/Liaison Signature

5 VERIFICATION OF SCHOOL SOCIAL WORK FIELD REQUIREMENTS (page 2 of 3) FIELD INSTRUCTION: Community Based Agency MSW Field Instructor License (LCSW, LMSW, etc.): If Instructor is not licensed, submit the Field Instructor Waver form to TSPC through School of Social Work Field Office by first week in winter term. Form available on School Social Work Licensure website. Fall Term: Orientation to Agency Completed Initial Personal Assessment Questionnaire (PAQ) Completed Field Educational Plan (FEP) due by the 5 th week of the term (to detail opportunities to work with children and youth of various ages) Initiation of service provision including case management and community linkages to children, youth and families Assessment of individuals, agency and community Weekly Supervision (attach Fall Timesheet) Fall Evaluation of Student Learning Winter Term: Individual and family work, with ongoing evaluation of practice Assessment of Community Resources Development of Macro Intervention and Evaluation Plan Weekly Supervision (attach Winter Timesheet) Winter Evaluation of Student Learning Submit Field Instructor Waver form (if applicable) Spring Term: Individual and family work with planned termination and evaluation Implementation and evaluation of Macro Intervention Weekly Supervision (attach Spring Timesheet) Complete End- of- Year PAQ Spring Evaluation of Student Learning Student Signature Faculty Advisor/Liaison Signature

6 VERIFICATION OF SCHOOL SOCIAL WORK FIELD REQUIREMENTS (page 3 of 3) FIELD INSTRUCTION: Direct Practice Requirements at least 15 hours with children ages 3-8 (specify which placement, term, year) Verified by: Name and Role Signature at least 15 hours with children ages 9-14 (specify which placement, term, year) Verified by: Name and Role Signature at least 15 hours with youth ages (specify which placement, term, year) Verified by: Name and Role Signature PROGRAM APPROVAL School Social Work License Chair (name and signature)

7 INSTRUCTIONS FOR APPLYING FOR THE OREGON (TSPC) INITIAL SCHOOL SOCIAL WORKER LICENSE OAR # (2) Applicants from Oregon approved programs must apply for licensure within three years following completion of their respective programs. If more than three years elapse before application is made, the candidate must qualify for recommendation under rules for licensure in effect at the time of application. Step #1 SUBMIT portfolio to the School of Social Work ATTN: Director of School Social Work Licensure. Portfolio includes: Licensure Program of Study form, Clinical Experience Summary Report, resume, four PAQ's, and the integrative paper. The portfolio will be reviewed and the Licensure Program of Study form and the Clinical Experience Summary Report returned to you with signatures for submission to GSE. Step #2 COLLECT Items Listed on the Student Checklist (see next page or flip side) Once you have collected all the items, please proceed to Step #3 below. SUBMIT Request for Licensure Recommendation Form & Fee Please TYPE directly into the Request for Licensure Recommendation form available at (along with the items on the File Review Checklist in one envelope) once you have confirmed that ALL your GRADES are POSTED. Step #3 Step #4 To submit the FORM and FEE, either: MAIL (or bring the form in-person) with a CHECK or money order made payable to PSU for $100 for the licensure processing fee --or-- (gse.licensure@pdx.edu) the form AFTER you pay the $100 licensure processing fee online with credit card at Online payments will include a $2.50 credit card fee. Forms will not be processed without payment. Before submission VERIFY: on form = you have on file with TSPC WAIT for your GSE file to be reviewed Your file will be completely reviewed once the Request for Recommendation Form is received. All items for licensure need to be in your GSE file. Your C-2 form is submitted to TSPC electronically by our office; you will not receive a paper copy of the C-2. Mid-June through September, it may take up to 3-4 weeks to review your file and recommend you to TSPC. RECEIVE from TSPC Step #5 Once you have been recommended by PSU to TSPC, you will receive the following message (or something similar): We have received the following document pertaining to your account: Program Completion Report (Form C-2) SEND Documents to TSPC After you receive the confirmation from TSPC, mail the following items to: TSPC, 250 Division St. NE, Salem OR Step #6 A completed C-1 form: 1_Instruct.aspx Payment to TSPC for $ (See C-1 Form link above for further instructions) PSU Official Transcript (official copy) Contact Information for TSPC: /

8 Contact Information and Mailing Addresses School of Social Work, Portland State University, PO Box 751, Portland, OR Web: Office of Licensure/Graduate School of Education, Portland State University, PO Box 751, Portland, OR Web: Student Checklist School Social Worker Please collect the following items prior to applying for your initial educator license, and submit these documents (in one complete packet) with your GSE Request for Licensure Recommendation Form Please Note: Your Master s degree (MSW) must be posted before you can proceed to Step #3. o o o Licensure Program of Study entire course list including signatures of Student, Advisor, and Program Director Clinical Experience Summary Report with needed signatures Basic Skills Test (photocopy of score report): CBEST or PRAXIS PPST or NES EAS Official actual scores must be listed, not just passing notification. All scores (Reading, Writing, and Math) need to be from one testing vendor; subtests cannot be mixed and matched o Civil Rights Test (photocopy of score report): (ORELA s Protecting Student and Civil Rights in the Educational Environment Examination) o Photocopy of PA-1 form or Clearance from TSPC document: A printout from the TSPC website of an Educator Look Up report with fingerprint clearances and dates. o Photocopy of your Bachelor s degree transcript -- with degree, major, date earned posted clearly. If you earned your Bachelor s