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Please fill out your contact information below. Please provide permanent contact information that will allow us to find you regardless of where you are working:

Last Name:

First Name:

Credentials:

What is your most permanent mailing address, city, state and zip. (This address will not be published or accessible to anyone but Zarrow School administration):

Is this address work, home or other?

Work
Home
Other

Email address (this is where you will receive practicum correspondence):

Work Phone number:

(e.g.. xxx-xxx-xxxx)

Fax Phone number:

(e.g.. xxx-xxx-xxxx)

Cell Phone Number:

(e.g.. xxx-xxx-xxxx)

To which OU Campus are you submitting an application?

Norman Campus
Tulsa Campus
Online Program

Employment Questions:

Place of employment:

When did you begin working there (MM/YYYY)

Current position/title (include program, department, unit, etc.):

When did you begin this position (MM/YYYY)

Social Work Degree:

BSW or equivalent (BA in Social Work/BSSW)
MSW or equivalent (MA in Social Work/MSSW)
Other / License

If other, please list degree / license:

"Other degree" year awarded

BSW year awarded:

MSW year awarded:

Granting university of highest social work degree (and campus if applicable):

Please read "Roles and Responsibilities of Field Instructors and Preceptors" which appears on pages 75-77 in the Field Education Manual. Please click here to review our manual. Please note, you will need to select the Field Education Manual that pertains to the student you will be working with.

Do you agree to these roles and responsibilities?

Yes
No

If no, please explain:

Did an O.U. Practicum student ask you to complete the application? If yes, which student?