2021 MASTER OF SOCIAL WORK (MSW) ADMISSION APPLICATION

APPLICATION INSTRUCTIONS Application Deadline: Friday, January 15, 2021

Please review the MSW Application Guidelines posted to our School of Social Work website.

Admission is a two-step process and admission to the School of Social Work is contingent upon admission to the University by Enrollment Services. The University (California State University, Long Beach) application is a separate process that requires a $70.00 fee. You will receive a Campus ID# (i.e. Student ID#) after submission of the University application; you must include this Campus ID# on pages 2 and 4 of this application. Official transcripts must be submitted to University Enrollment Services by January 15, 2021.

You must submit a complete application packet to the School of Social Work and the School will not process any application that is missing documents or information. A complete application packet includes the following:

• pages 2 through 11 of this 2021 application,• résumé,• Personal and Professional statement,• three (3) School of Social Work 2021 MSW Reference Forms,• and a statistics course syllabus (if the course you completed was not included on the list of

approved courses that is posted to our website).

Applications are accepted on a rolling admission basis and are reviewed on a first-come, first-served basis until spaces are filled.

Fall 2021 Supplemental Applications must be submitted to the School of Social Work electronically to the following email address: CHHS-SWApplications@csulb.edu. Detailed application instructions can be found on the School of Social Work website, please follow all guidelines and processes outlined in the Application Instruction document when submitting your application packet.

Reference Form documents should be submitted electronically from the Referent to the CHHS-SWApplications@csulb.edu email account.

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http://www.csulb.edu/colleges/chhs/departments/social-work/master-of-social-work/

2021 MASTER OF SOCIAL WORK (MSW) ADMISSION APPLICATION APPLICATION CHECKLIST

University Graduate Admission Application at Cal State Apply

Official Transcripts submitted to University Enrollment Services (Transcript Deadline: January 15, 2021)

School of Social Work Fall 2021 MSW Application (signed and dated)

Elementary Statistics Course Verified OR Elementary Statistics Course Syllabus Enclosed

Résumé (see guidelines, page 7)

Personal and Professional Statement

Three School of Social Work MSW Reference Forms (submitted electronically by Referent, see page 7)

SECTION ONE: APPLICANT INFORMATION 1. CSULB 9-DIGIT CAMPUS ID# (REQUIRED)

2. BIRTHDATE (MM/DD/YEAR)

3. FIRST, MIDDLE AND LAST NAME

4. STREET ADDRESS (PLEASE INCLUDE STREET, CITY, STATE AND ZIP CODE)

5. PHONE NUMBERS (PLEASE INCLUDE BOTH CELL PHONE AND HOME PHONE)

6. EMAIL ADDRESS

7. GENDER (PLEASE SELECT YOUR GENDER. IF OTHER, PLEASE SELECT “OTHER” AND SPECIFY)

FEMALE MALE TRANSGENDER DECLINE TO STATE OTHER

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http://www.calstate.edu/apply

8. ETHNICITY (PLEASE SELECT YOUR ETHNICITY OR ETHNICITIES)

AFRICAN AMERICAN/OTHER BLACK

AMERICAN INDIAN/NATIVE AMERICAN

ASIAN AMERICAN/OTHER ASIAN

CHICANO/MEXICAN-AMERICAN

PUERTO RICAN

OTHER LATINO(A)/HISPANIC

PACIFIC ISLANDER/NATIVE HAWAIIAN

WHITE/CAUCASIAN

MULTIPLE RACE/ETHNICITY

OTHER (SPECIFY)

DECLINE TO STATE

9. UNITED STATES CITIZENSHIP STATUS

Please indicate your Citizenship status below.

Note: If you are applying as an international student and do not have Permanent Resident status, you must contact the Center for International Education at 562-985-5555 or cie-admission@csulb.edu. This is a critical step in the admission process. Applicants who possess a Bachelor’s degree from a college or university where English is not the primary language of instruction must pass the Test of English as a Foreign Language (TOEFL).

CITIZEN PERMANENT RESIDENT DACA OTHER (SPECIFY)

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mailto:cie-admission@csulb.edu

SECTION TWO: ACADEMIC INFORMATION 1. LAST NAME, FIRST NAME AND CSULB ID#

PROGRAM PLAN PROGRAMS: We offer 2-Year, 3-Year, and Advanced Standing programs to complete the MSW degree. Nomination to a selected program depends on faculty assessment of applications and availability. Advanced Standing applicants must have earned a Bachelor of Social Work degree (with a minimum cumulative GPA of 3.0) within the past five (5) years from a CSWE-accredited program by the end of the spring semester/quarter prior to starting the MSW program.

SPECIALIZATIONS: We offer study in three areas of specialization: Adulthood & Aging (A&A), Child & Family Wellbeing (CFW), and Integrated Health (IH). Advanced Standing students are assigned a specialization at the time of admission, so applicants to the Advanced Standing program must rank their specialization preference at the time of application. Specializations for 2-Year and 3-Year students will be identified during the course of the program.

2. PROGRAM PLAN

Select your choice of program plan(s): rank your program plan choices, including the third choice if applicable, below. List your 1st choice on the outside of your application packet envelope.

1ST CHOICE

2-YEAR 3-YEAR AS A&A AS CFW AS IH

2ND CHOICE

2-YEAR 3-YEAR AS A&A AS CFW AS IH

3RD CHOICE (IF APPLICABLE)

2-YEAR 3-YEAR AS A&A AS CFW AS IH

3. STIPENDS AND SPECIAL PROGRAMS

Please indicate interest in our Stipend and Special Programs. (Check all that Apply)

PUPIL PERSONNEL SERVICES CREDENTIAL (PPSC)

CALSWEC PUBLIC CHILD WELFARE PROGRAMS

LAC DMH MENTAL HEALTH STIPEND PROGRAMS

L.A. DCFS UNIVERSITY CONSORTIUM OF CHILDREN & FAMILIES (UCCF) STIPEND

GERIATRIC SOCIAL WORK EDUCATION CONSORTIUM (GSWEC) STIPEND

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ACADEMIC RECORD 4. ACADEMIC RECORD (PLEASE INCLUDE THE COLLEGE/UNIVERSITY, DATES ATTENDED, MAJOR AND DEGREE COMPLETED)

List all of your academic work beyond high school below. An official transcript from each institution must be submitted directly to University Enrollment Services no later than January 15, 2021 (do not include your transcripts in your application packet to the School of Social Work; transcripts must be sent directly to University Enrollment Services). You must complete a baccalaureate degree from an accredited college or university by the end of the spring semester/quarter prior to starting the MSW program.

5. PREVIOUS PROGRAM

Were you previously enrolled in another MSW Program? If Yes, you must provide a letter from the Dean/Director of the school previously attended documenting your academic status. You must also provide a letter from the Director/Coordinator of field education documenting your performance while enrolled in the program.

YES NO

6. REAPPLYING APPLICANTS

Are you reapplying to the CSULB MSW program?

YES

YEARS PREVIOUSLY APPLIED

NO

7. OTHER SCHOOLS (OPTIONAL)

Are you planning to apply to other schools of social work?

YES

LIST SCHOOLS

NO

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8. GRADE POINT AVERAGE

The School of Social Work requires a minimum cumulative GPA of 2.5. You must have at least a 2.5 GPA at the time you apply to our program.

CUMULATIVE GPA NUMBER OF UNITS

9. PRE-REQUISITE COURSE

An approved course in Elementary Statistics (in any subject area) is a pre-requisite requirement for admission to the MSW program.

The course must be completed by the end of the spring semester/quarter prior to starting the MSW program. You must earn a grade of “C” or better in the statistics course; we have posted a list of approved courses on our website. If your course is not included on the approved courses list, you must submit a copy of the course syllabus in your application packet.

Please list below the information regarding your Elementary Statistics course – for approved courses that have transferred into another institution, please list the original approved course information prior to transfer.

COURSE NUMBER

COURSE TITLE

COLLEGE/UNIVERSITY

SEMESTER/YEAR

UNITS

COURSE STATUS/GRADE

COMPLETE IN-PROGRESS GRADE

APPROVED COURSE

Is this course included on our list of approved courses?

YES NO (COPY OF THE COURSE SYLLABUS ENCLOSED IN APPLICATION PACKET)

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http://www.csulb.edu/colleges/chhs/departments/social-work/master-of-social-work/

SECTION THREE: RÉSUMÉ AND PERSONAL AND PROFESSIONAL STATEMENT 10. EXPERIENCE/RÉSUMÉ

You must include a current résumé in your application packet. List your most recent social work or social work-related experience first. Include all paid, internship, and volunteer experience in your résumé. For each position, you must list the following information:

• Organization / Agency Name and City / State• Type of position: Volunteer / Internship / Paid• Your Title• Start date & End date• Number of hours per week or month [Examples: “25 hours per week”, “15 hours per month”]• Title of immediate supervisor• Detailed description of your duties

Please note that students are not given credit toward degree requirements for life experience.

11. AGENCY EMPLOYMENT

Are you currently working for one of the following agencies?

L.A. COUNTY DEPARTMENT OF CHILDREN AND FAMILY SERVICES

LOS ANGELES COUNTY DEPARTMENT OF PUBLIC SOCIAL SERVICES

ORANGE COUNTY SOCIAL SERVICES AGENCY

OTHER PUBLIC CHILD WELFARE OR SOCIAL SERVICE AGENCY

12. PERSONAL AND PROFESSIONAL STATEMENT

You must include a Personal and Professional Statement in your application packet. It should be typed, double-spaced, 12 pt. font, 4 - 6 pages in length and address the areas of discussion on page 12 of this application. Carefully read and follow the instructions & guidelines provided on page 12. Applicants who wish to be considered for the Advanced Standing program must answer Question #10 in addition to Questions #1 -9.

SECTION FOUR: REFERENCE INFORMATION 13. REFERENCES

You must include three (3) completed School of Social Work 2021 MSW Reference Forms in your application packet (see pages 14 - 19). You must complete Section One (including the initial box) on each Reference Form BEFORE you provide the form to your Reference. You must list the name and information for each reference below.

At least one reference must be from an academic source and at least one must be from a professional source. A reference from your current supervisor is preferred, especially if social work-related (i.e. work, volunteer, or internship). Personal references are not acceptable.

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KAISER PERMANENTE MENTAL HEALTH SCHOLARS ACADEMY

A letter on official letterhead can be included with a Reference Form, but a letter cannot be submitted in place of a Reference Form.

Forms from other institutions will not be accepted. School of Social Work Reference Forms should be submitted electronically directly from the person completing the Reference Form to the School of Social Work Admissions Office CHHS-SWApplications@csulb.edu email account.

**NOTE for Advanced Standing Applicants: In order to be considered for the Advanced Standing program, you must submit Reference Forms from the following references and indicate the specific reference in the table below:

(1) Your Senior-Year field instructor/field supervisor or field liaison or the Director/Coordinator of fieldeducation for your BASW/BSW program OR if you graduated two or more years ago and work in thesocial work field, your current supervisor

(2) your Social Work Academic Advisor or a Social Work (BASW/BSW) professor whose course youcompleted or are currently taking

(3) a professional reference (i.e. a supervisor from a paid or volunteer position NOT from your BSWinternship)

All Applicants: List the name and information for your three (3) references.

Advanced Standing Applicants Only: Specify required reference (example, Field Instructor) – see note above.

REFERENCE #1: NAME

TITLE

INSTITUTION/ORGANIZATION

PHONE NUMBER

EMAIL ADDRESS

REFERENCE TYPE

PROFESSIONAL ACADEMIC

REQUIRED REFERENCE (ADVANCED STANDING ONLY)

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FIELD INSTRUCTOR/SUPERVISOR FIELD LIAISON FIELD DIRECTOR/COORDINATOR

CURRENT SW SUPERVISOR ACADEMIC ADVISOR BASW/BSW PROFESSOR

REFERENCE #2: NAME

TITLE

INSTITUTION/ORGANIZATION

PHONE NUMBER

EMAIL ADDRESS

REFERENCE TYPE

PROFESSIONAL ACADEMIC

REQUIRED REFERENCE (ADVANCED STANDING ONLY)

FIELD INSTRUCTOR/SUPERVISOR FIELD LIAISON FIELD DIRECTOR/COORDINATOR

CURRENT SW SUPERVISOR ACADEMIC ADVISOR BASW/BSW PROFESSOR

REFERENCE #3: NAME

TITLE

INSTITUTION/ORGANIZATION

PHONE NUMBER

EMAIL ADDRESS

REFERENCE TYPE 9 | P a g e

PROFESSIONAL ACADEMIC

REQUIRED REFERENCE (ADVANCED STANDING ONLY)

FIELD INSTRUCTOR/SUPERVISOR FIELD LIAISON FIELD DIRECTOR/COORDINATOR

CURRENT SW SUPERVISOR ACADEMIC ADVISOR BASW/BSW PROFESSOR

SECTION FIVE: LEARN ABOUT PROGRAM 14. HOW DID YOU LEARN ABOUT THE CSULB SCHOOL OF SOCIAL WORK? (CHECK ALL THAT APPLY)

CSULB SCHOOL OF SOCIAL WORK INFORMATION MEETING

SCHOOL OF SOCIAL WORK WEBSITE

PERSONAL REFERENCE

PROFESSIONAL/GRADUATE STUDENT FAIR

LOCATION

PRESENTATION AT PLACE OF EMPLOYMENT

LOCATION

OTHER

SECTION SIX: APPLICATION INFORMATION PLEASE READ THE FOLLOWING IMPORTANT INFORMATION AND SIGN/DATE ON THE SIGNATURE LINE.

The applicant is responsible for assembling the application packet prior to submitting it to the School of Social Work Admissions Office. The application packet must include the following:

• pages 2 through 11 of this 2021 application,• résumé,• Personal and Professional statement,• three (3) School of Social Work 2021 MSW Reference Forms (submitted electronically by

Referents),• and a statistics course syllabus (if the course you completed was not included on the list of

approved courses that is posted to our website).All materials submitted to the School of Social Work become official University property. Official transcripts must be submitted to University Enrollment Services by January 15, 2021. Applications are accepted on a rolling admission basis and are reviewed on a first-come, first-served basis until spaces are filled. Incomplete and late applications will not be evaluated.

PLEASE NOTE: Interviews may be required if further clarification is needed in order for the evaluators to make an informed decision on the application.

It is understood that in applying to the CSULB School of Social Work the applicant is aware of the necessary

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commitment of time, effort, and finances for the rigors of graduate study and professional social work. The School of Social Work reserves the right, on the basis of educational or professional judgment, to reject an applicant or to dismiss an admitted student whose academic record or performance in field instruction does not meet minimum expectations or is not consistent with the accepted standards for professional behavior.

The School of Social Work determines the field work agencies to which students will be assigned, and the majority of field work agencies are located in low income, urban areas. If admitted to the MSW program, the student agrees to accept the field work placement assigned by the field faculty of the School. Once admitted to a particular program plan, students are not allowed to change plans except with the permission of the Graduate Program Coordinator.

**Please be aware that as social workers, we are mandated by law to report incidents of child or older adult abuse.**

Your signature below certifies that you have read and understood the above statements and that all materials you have submitted for consideration are complete and accurate.

15. APPLICANT SIGNATURE AND DATE

California State University, Long Beach provides equal opportunity in education without regard to race, color, national origin, sex, gender, sexual orientation or disability in accordance with Title VI of the Civil Rights Act of 1964, Title IX of the Educational Amendments of 1972, and Section 604 of the Vocational Rehabilitation Act of 1973.

SECTION SEVEN: APPLICATION DELIVERY INSTRUCTIONS Fall 2021 Supplemental Applications must be submitted to the School of Social Work electronically to the following email address: CHHS-SWApplications@csulb.edu. Detailed application instructions can be found on the School of Social Work website, please follow all guidelines and processes outlined in the Application Instruction document when submitting your application packet.

Reference Form documents should be submitted electronically from the Referent to the CHHS-SWApplications@csulb.edu email account.

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SECTION EIGHT: PERSONAL AND PROFESSIONAL STATEMENT GUIDELINES The Personal and Professional Statement provides you the opportunity to share your qualifications and competencies. This Personal and Professional Statement will be used to evaluate your critical thinking, self-reflective capacities, creativity, and advanced writing skills, as well as help us determine your appropriateness for the program and the profession. Failure to follow these guidelines or address each area of discussion will impact your application.

INSTRUCTIONS: Your Personal and Professional Statement must meet the following criteria:

• It must be written by you.• It must be typed, double-spaced, 12 pt. font, and 4 - 6 pages in length.• It must address each of the prompts/questions and areas of discussion below.• You have the option to write a narrative/essay or number your responses (do not include the

prompts/questions in your Personal and Professional Statement).• In answering these prompts/questions, make sure not to use names or information that might violate

the confidentiality of the individuals you decide to use in your descriptions.

PROMPTS/QUESTIONS & AREAS OF DISCUSSION:

1. How did you become interested in social work? What motivated you to choose social work as aprofession?

2. Describe some traits and abilities that make you particularly suited for the profession of social work.

3. Specify your career objectives as a professional social worker.

4. Describe your professional social work activities. If you do not currently work in the social work field,describe how your work or volunteer experience relates to professional social work activities. Please beas specific as possible in detailing the similarity to social work activities.

5. Describe a situation in which you were confronted with an ethical conflict. How did you resolve it?

6. Our School of Social Work has a strong multicultural emphasis and values diversity. Please describe yourexperience(s) with diverse individuals and/or communities. (Differences can include age, socioeconomicstatus, race, ethnicity, religion, gender, physical or mental abilities, sexual orientation, etc.). Discuss howthese experiences have:• Shaped your identity and self-awareness• Broadened your understanding of the role of social work in society• Influenced your understanding of and commitment to social justice

7. Discuss a social problem of interest to you. How do you envision a social worker’s role in addressing theissue?

8. Please read the information about our MSW program below and describe your plan to accommodate theclass and field internship requirements and expected demands of our MSW program.

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PLEASE READ: Our MSW program is rigorous and requires a significant commitment of time and resources from students. In order to answer Question #8, be sure to review the course schedule requirements for the program plan(s) for which you are applying that are posted on our website. In addition to coursework, students complete 16 hours per week in field internship during regular agency hours. The exact schedule is determined by the student and the agency at the time of placement. Most students complete two full 8-hour days; however, at the discretion of the agency, some students may be permitted to complete the16 hours in an alternate schedule of one 8-hour day and two 4-hour days.

9. Is there anything else you would like us to know as we consider your application? Please describe.

10. Advanced Standing Applicants Only: Please explain why you think you are a good fit for the AdvancedStanding (AS) program. In addition to meeting the minimum requirements for the AS program, what doyou believe has prepared you to succeed in this accelerated program?

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2021 MASTER OF SOCIAL WORK (MSW) REFERENCE FORM

PROFESSIONAL REFERENCE ACADEMIC REFERENCE

SECTION ONE: INSTRUCTIONS TO THE APPLICANT

You must first complete Section One of this form (including the waiver box) and then provide the form to your reference via email. The reference must return the completed reference form (six pages) to the School of Social electronically to CHHS-SWApplications@csulb.edu. Please note that we reserve the right to contact the Reference for clarification and/or verification.

1. APPLICANT NAME

2. DATE OF REQUEST

3. REFERENCE NAME

4. REFERENCE PROFESSIONAL DEGREE/OTHER CREDENTIAL

5. REFERENCE POSITION TITLE

6. REFERENCE ORGANIZATION NAME

7. REFERENCE STREET ADDRESS (PLEASE INCLUDE STREET, CITY, STATE AND ZIP CODE)

8. REFERENCE PHONE NUMBER

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9. REFERENCE EMAIL ADDRESS

APPLICANT RIGHTS WAIVER Note: The following must be completed and initialed by the applicant before forwarding this form to the reference.

Under the provisions of the Family Educational Rights and Privacy Act of 1974, as amended, the applicant, if admitted and enrolled, will be entitled to access the information provided on this form unless the applicant waives their right to review this reference.

10. RIGHTS WAIVER (PLEASE CHECK ONE)

I WAIVE MY RIGHT TO REVIEW THIS REFERENCE.

I DO NOT WAIVE MY RIGHT TO REVIEW THIS REFERENCE.

In accordance with the Family Educational Rights and Privacy Act of 1974, I give permission to release confidential information for the purpose of application to the CSULB Master of Social Work Program.

11. APPLICANT INITIALS AND DATE

SECTION TWO: INSTRUCTIONS TO THE REFERENCE The above-named individual has applied for admission to the Master of Social Work Program at California State University, Long Beach. Your assessment of the applicant will assist the Admissions Committee. This form is required, but you are welcome to include a letter in addition to this form. School of Social Work Reference Forms should be submitted electronically directly from the Referent to the School of Social Work Admissions Office CHHS-SWApplications@csulb.edu email account.

1. HOW LONG HAVE YOU KNOWN THE APPLICANT?

2. IN WHAT CAPACITIES HAVE YOU KNOWN THE APPLICANT? (CHECK ALL THAT APPLY)PROFESSOR INSTRUCTOR ACADEMIC ADVISOR RESEARCH SUPERVISOR

SUPERVISOR DIRECTOR PROGRAM FIELD INSTRUCTOR

OTHER (MUST SPECIFY)

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3. LIST SKILLS THAT DEMONSTRATE THE APPLICANT’S POTENTIAL IN THE SOCIAL WORK PROFESSION.

4. LIST AREAS THAT NEED FURTHER DEVELOPMENT TO ENHANCE THE APPLICANT’S EFFECTIVENESS AS A SOCIAL WORK.

APPLICANT EVALUATION 5. PLEASE RATE THE APPLICANT RELATIVE TO OTHER STUDENTS OR EMPLOYEES WHOM YOU HAVE KNOWN IN THE SAME FIELD IN

RECENT YEARS FOR EACH CATEGORY. EXPLAIN AS NEEDED IN THE COMMENTS SECTION. PLEASE FEEL FREE TO ATTACH ADDITIONAL SHEETS.• ABILITY TO CONCEPTUALIZE, ORGANIZE AND COMMUNICATE IDEAS (VERBAL AND WRITTEN)

1: BELOW AVERAGE (BOTTOM 50%) 2: AVERAGE (TOP 40%) 3: GOOD (TOP 30%) 4: SUPERIOR (TOP 20%) 5: EXCEPTIONAL (TOP 10%) N/A: UNABLE TO EVALUATE

COMMENTS:

• CAPACITY FOR SELF-AWARENESS1: BELOW AVERAGE (BOTTOM 50%) 2: AVERAGE (TOP 40%) 3: GOOD (TOP 30%) 4: SUPERIOR (TOP 20%) 5: EXCEPTIONAL (TOP 10%) N/A: UNABLE TO EVALUATE

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COMMENTS:

• ABILITY TO ESTABLISH AND MAINTAIN RELATIONSHIPS WITH PEERS 1: BELOW AVERAGE (BOTTOM 50%) 2: AVERAGE (TOP 40%) 3: GOOD (TOP 30%) 4: SUPERIOR (TOP 20%) 5: EXCEPTIONAL (TOP 10%) N/A: UNABLE TO EVALUATE

COMMENTS:

• ABILITY TO ESTABLISH AND MAINTAIN RELATIONSHIPS WITH SUPERVISORS1: BELOW AVERAGE (BOTTOM 50%) 2: AVERAGE (TOP 40%) 3: GOOD (TOP 30%) 4: SUPERIOR (TOP 20%) 5: EXCEPTIONAL (TOP 10%) N/A: UNABLE TO EVALUATE

COMMENTS:

• ABILITY TO ESTABLISH AND MAINTAIN RELATIONSHIPS WITH CLIENTS1: BELOW AVERAGE (BOTTOM 50%) 2: AVERAGE (TOP 40%) 3: GOOD (TOP 30%) 4: SUPERIOR (TOP 20%) 5: EXCEPTIONAL (TOP 10%) N/A: UNABLE TO EVALUATE

COMMENTS:

• SENSITIVITY TO ISSUES OF ETHNICITY, GENDER, AGE, ABILITY, RELIGIOUS AND SEXUAL ORIENTATION1: BELOW AVERAGE (BOTTOM 50%) 2: AVERAGE (TOP 40%) 3: GOOD (TOP 30%) 4: SUPERIOR (TOP 20%) 5: EXCEPTIONAL (TOP 10%) N/A: UNABLE TO EVALUATE

COMMENTS:

• MATURITY AND EMOTIONAL STABILITY1: BELOW AVERAGE (BOTTOM 50%) 2: AVERAGE (TOP 40%) 3: GOOD (TOP 30%) 4: SUPERIOR (TOP 20%) 5: EXCEPTIONAL (TOP 10%) N/A: UNABLE TO EVALUATE

COMMENTS:

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• ABILITY TO TREAT EVERYONE WITH DIGNITY AND RESPECT1: BELOW AVERAGE (BOTTOM 50%) 2: AVERAGE (TOP 40%) 4: SUPERIOR (TOP 20%) 5: EXCEPTIONAL (TOP 10%)

COMMENTS:

3: GOOD (TOP 30%) N/A: UNABLE TO EVALUATE

• OPENNESS TO LEARNING WITH CAPACITY TO CHANGE1: BELOW AVERAGE (BOTTOM 50%) 2: AVERAGE (TOP 40%) 4: SUPERIOR (TOP 20%) 5: EXCEPTIONAL (TOP 10%)

COMMENTS:

3: GOOD (TOP 30%) N/A: UNABLE TO EVALUATE

• ABILITY TO ACCEPT CONSTRUCTIVE FEEDBACK1: BELOW AVERAGE (BOTTOM 50%) 2: AVERAGE (TOP 40%) 4: SUPERIOR (TOP 20%) 5: EXCEPTIONAL (TOP 10%)

COMMENTS:

3: GOOD (TOP 30%) N/A: UNABLE TO EVALUATE

• INTEGRITY AND HONESTY 1: BELOW AVERAGE (BOTTOM 50%) 2: AVERAGE (TOP 40%) 3: GOOD (TOP 30%) 4: SUPERIOR (TOP 20%) 5: EXCEPTIONAL (TOP 10%) N/A: UNABLE TO EVALUATE

COMMENTS:

• ABILITY TO MAKE SOUND JUDGEMENTS1: BELOW AVERAGE (BOTTOM 50%) 2: AVERAGE (TOP 40%) 3: GOOD (TOP 30%) 4: SUPERIOR (TOP 20%) 5: EXCEPTIONAL (TOP 10%) N/A: UNABLE TO EVALUATE

COMMENTS:

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• EFFECTIVENESS IN WORKING WITH CULTURALLY DIFFERENT INDIVIDUALS AND/OR GROUPS1: BELOW AVERAGE (BOTTOM 50%) 2: AVERAGE (TOP 40%) 3: GOOD (TOP 30%) 4: SUPERIOR (TOP 20%) 5: EXCEPTIONAL (TOP 10%) N/A: UNABLE TO EVALUATE

COMMENTS:

REFERENT RECOMMENDATION 6. PLEASE INDICATE YOUR OVERALL RECOMMENDATION BY CHECKING THE APPROPRIATE BOX.

I HIGHLY RECOMMEND THE APPLICANT FOR YOUR PROGRAM.

I RECOMMEND THE APPLICANT FOR YOUR PROGRAM.

I THINK THE APPLICANT IS NOT SUITED FOR YOUR PROGRAM.

7. REFERENT SIGNATURE AND DATE

REFERENCE FORM DELIVERY INSTRUCTIONS Feel free to make further comments on additional sheets and include with this form. School of Social Work Reference Forms should be submitted electronically directly from the Referent to the School of Social Work Admissions Office CHHS-SWApplications@csulb.edu email account.

The documents should not be sent back to the applicant for submission to the School of Social Work, those documents would not be accepted.

California State University, Long Beach provides equal opportunity in education without regard to race, color, national origin, sex, gender, sexual orientation or disability in accordance with Title VI of the Civil Rights Act of 1964, Title IX of the Educational Amendments of 1972, and Section 604 of the Vocational Rehabilitation Act of 1973.

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University Graduate Admission Application at Cal State Apply: OffOfficial Transcripts submitted to University Enrollment Services Transcript Deadline January 15 2021: OffSchool of Social Work Fall 2021 MSW Application signed and dated: OffPersonal and Professional Statement: OffElementary Statistics Course Syllabus Enclosed: OffFEMALE: OffMALE: OffTRANSGENDER: OffPUERTO RICAN: OffCITIZEN: OffPERMANENT RESIDENT: OffDACA: OffCALSWEC PUBLIC CHILD WELFARE PROGRAMS: OffLAC DMH MENTAL HEALTH STIPEND PROGRAMS: OffLA DCFS UNIVERSITY CONSORTIUM OF CHILDREN FAMILIES UCCF STIPEND: OffGERIATRIC SOCIAL WORK EDUCATION CONSORTIUM GSWEC STIPEND: OffLA COUNTY DEPARTMENT OF CHILDREN AND FAMILY SERVICES: OffLOS ANGELES COUNTY DEPARTMENT OF PUBLIC SOCIAL SERVICES: OffORANGE COUNTY SOCIAL SERVICES AGENCY: OffCSULB SCHOOL OF SOCIAL WORK INFORMATION MEETING: OffSCHOOL OF SOCIAL WORK WEBSITE: OffPERSONAL REFERENCE: OffPRESENTATION AT PLACE OF EMPLOYMENT: OffPROFESSIONAL REFERENCE: OffACADEMIC REFERENCE: OffPROFESSOR: OffINSTRUCTOR: OffRESEARCH SUPERVISOR: OffSUPERVISOR: OffDIRECTOR: OffPROGRAM: OffFIELD INSTRUCTOR: OffCSULB 9DIGIT CAMPUS ID: BIRTHDATE: FIRST MIDDLE AND LAST NAME: STREET ADDRESS: PHONE NUMBERS: EMAIL ADDRESS: OTHER GENDER: OffOTHER GENDER TEXT: OTHER ETHNICITY: OffOTHER ETHNICITY TEXT: DECLINE TO STATE ETHNICITY: OffDECLINE TO STATE GENDER: OffOTHER CITIZENSHIP: OffOTHER CITIZENSHIP TEXT: LAST NAME FIRST NAME AND CSULB ID: 1ST CHOICE 2YEAR: Off1ST CHOICE 3YEAR: Off1ST CHOICE AS AA: Off1ST CHOICE AS CFW: Off1ST CHOICE AS IH: Off2ND CHOICE 2YEAR: Off2ND CHOICE 3YEAR: Off2ND CHOICE AS AA: Off2ND CHOICE AS CFW: Off2ND CHOICE AS IH: Off3RD CHOICE 2YEAR: Off3RD CHOICE 3YEAR: Off3RD CHOICE AS AA: Off3RD CHOICE AS CFW: Off3RD CHOICE AS IH: OffACADEMIC RECORD: PREVIOUS PROGRAM NO: OffPREVIOUS PROGRAM YES: OffREAPPLYING YES: OffYEARS PREVIOUSLY APPLIED: REAPPLYING NO: OffAPPLY TO OTHER SCHOOLS YES: OffLIST OF OTHER SCHOOLS: APPLY TO OTHER SCHOOL NO: OffCUMULATIVE GPA: CUMULATIVE GPA UNITS: STATS COURSE NUMBER: STATS COURSE TITLE: STATS COLLEGE/UNIVERSITY: STATS SEMESTER/YEAR: STATS UNITS: STATS COMPLETE: OffSTATS INPROGRESS: OffSTATS GRADE: STATS NOT APPROVED SYLLABUS: OffOTHER CHILD WELFARE/SOCIAL SERVICE AGENCY: OffOTHER PUBLIC CHILD WELFARE OR SOCIAL SERVICE AGENCY TEXT: REFERENCE #1 NAME: REFERENCE #1 TITLE: REFERENCE #1 INSTITUTION/ORGANIZATION: REFERENCE #1 PHONE NUMBER: REFERENCE #1 EMAIL ADDRESS: REFERENCE #1 PROFESSIONAL: OffREFERENCE #1 FIELD INSTRUCTOR/SUPERVISOR: OffREFERENCE #1 FIELD LIAISON: OffREFERENCE #1 FIELD DIRECTOR/COORDINATOR: OffREFERENCE #1 CURRENT SW SUPERVISOR: OffREFERENCE #1 ACADEMIC ADVISOR: OffREFERENCE #1 BASW/BSW PROFESSOR: OffREFERENCE #2 NAME: REFERENCE #2 TITLE: REFERENCE #2 INSTITUTION/ORGANIZATION: REFERENCE #2 PHONE NUMBER: REFERENCE #2 EMAIL ADDRESS: REFERENCE #2 PROFESSIONAL: OffREFERENCE #2 ACADEMIC: OffREFERENCE #2 FIELD INSTRUCTOR/SUPERVISOR: OffREFERENCE #2 FIELD LIAISON: OffREFERENCE #2 FIELD DIRECTOR/COORDINATOR: OffREFERENCE #2 CURRENT SW SUPERVISOR: OffREFERENCE #2 ACADEMIC ADVISOR: OffREFERENCE #2 BASW/BSW PROFESSOR: OffREFERENCE #3 NAME: REFERENCE #3 TITLE: REFERENCE #3 INSTITUTION/ORGANIZATION: REFERENCE #3 PHONE NUMBER: REFERENCE #3 EMAIL ADDRESS: REFERENCE #3 PROFESSIONAL: OffREFERENCE #3 ACADEMIC: OffREFERENCE #3 FIELD INSTRUCTOR/SUPERVISOR: OffREFERENCE #3 FIELD LIAISON: OffREFERENCE #3 FIELD DIRECTOR/COORDINATOR: OffREFERENCE #3 CURRENT SW SUPERVISOR: OffREFERENCE #3 ACADEMIC ADVISOR: OffREFERENCE #3 BASW/BSW PROFESSOR: OffPROFESSIONAL/GRADUATE STUDENT FAIR TEXT: PRESENTATION AT PLACE OF EMPLOYMENT TEXT: LEARN ABOUT THE PROGRAM OTHER: OffLEARN ABOUT THE PROGRAM OTHER TEXT: APPLICANT NAME: DATE OF REFERENCE REQUEST: REFERENT NAME: REFERENT DEGREE/CREDENTIAL: REFERENT POSITION TITLE: REFERENT ORGANIZATION NAME: REFERENT ADDRESS: REFERENT PHONE NUMBER: REFERENT EMAIL ADDRESS: LONG HAVE YOU KNOWN APPLICANT: OTHER CAPACITY: OffOTHER CAPACITY TEXT: POTENTIAL SKILLS: AREAS FUTHER DEVELOPMENT: ABILITY TO CONCEPTUALIZE: BELOW AVERAGE BOTTOM 50: OffABILITY TO CONCEPTUALIZE: GOOD TOP 30: OffABILITY TO CONCEPTUALIZE; AVERAGE TOP 40: OffABILITY TO CONCEPTUALIZE: SUPERIOR TOP 20: OffABILITY TO CONCEPTUALIZE: EXCEPTIONAL TOP 10: OffABILITY TO CONCEPTUALIZE: N/A: OffABILITY TO CONCEPTUALIZE TEXT: SELF-AWARENESS: BELOW AVERAGE BOTTOM 50: OffSELF-AWARENESS: AVERAGE TOP 40: OffSELF-AWARENESS: GOOD TOP 30: OffSELF-AWARENESS: SUPERIOR TOP 20: OffSELF-AWARENESS: EXCEPTIONAL TOP 10: OffSELF-AWARENESS: N/A: OffSELF-AWARNESS TEXT: RELATIONSHIP WITH PEERS: BELOW AVERAGE BOTTOM 50: OffRELATIONSHIP WITH PEERS: AVERAGE TOP 40: OffRELATIONSHIP WITH PEERS: GOOD TOP 30: OffRELATIONSHIP WITH PEERS: SUPERIOR TOP 20: OffRELATIONSHIP WITH PEERS TEXT: RELATIONSHIP WITH SUPERVISORS: BELOW AVERAGE BOTTOM 50: OffRELATIONSHIP WITH SUPERVISORS: AVERAGE TOP 40: OffRELATIONSHIP WITH SUPERVISORS: GOOD TOP 30: OffRELATIONSHIP WITH SUPERVISORS: SUPERIOR TOP 20: OffRELATIONSHIP WITH SUPERVISORS: EXCEPTIONAL TOP 10: OffRELATIONSHIP WITH SUPERVISORS: N/A: OffRELATIONSHIP WITH SUPERVISORS TEXT: RELATIONSHIP WITH CLIENTS: BELOW AVERAGE BOTTOM 50: OffRELATIONSHIP WITH CLIENTS: AVERAGE TOP 40: OffRELATIONSHIP WITH CLIENTS: GOOD TOP 30: OffRELATIONSHIP WITH CLIENTS: SUPERIOR TOP 20: OffRELATIONSHIP WITH CLIENTS: EXCEPTIONAL TOP 10: OffRELATIONSHIP WITH CLIENTS: N/A: OffRELATIONSHIP WITH CLIENTS TEXT: SENSITIVITY TO ISSUES: BELOW AVERAGE BOTTOM 50: OffSENSITIVITY TO ISSUES: AVERAGE TOP 40: OffSENSITIVITY TO ISSUES: GOOD TOP 30: OffSENSITIVITY TO ISSUES: SUPERIOR TOP 20: OffSENSITIVITY TO ISSUES: EXCEPTIONAL TOP 10: OffSENSITIVITY TO ISSUES: N/A: OffSENSITIVITY TO ISSUES TEXT: MATURITY: BELOW AVERAGE BOTTOM 50: OffMATURITY: AVERAGE TOP 40: OffMATURITY: GOOD TOP 30: OffMATURITY: SUPERIOR TOP 20: OffMATURITY: EXCEPTIONAL TOP 10: OffMATURITY: N/A: OffMATURITY TEXT: ABILITY TREAT WITH D/R: BELOW AVERAGE BOTTOM 50: OffABILITY TREAT WITH D/R: AVERAGE TOP 40: OffABILTY TREAT WITH D/R: N/A: OffABILTY TREAT WITH D/R: EXCEPTIONAL TOP 10: OffABILITY WITH TREAT D/R: SUPERIOR TOP 20: OffABILITY TREAT WITH D/R: GOOD TOP 30: OffABILITY TO TREAT WITH DIGNITY AND RESPECT TEXT: OPENESS/CHANGE: BELOW AVERAGE BOTTOM 50: OffOPENESS/CHANGE: AVERAGE TOP 40: OffOPENESS/CHANGE: GOOD TOP 30: OffOPENESS/CHANGE: SUPERIOR TOP 20: OffOPENESS/CHANGE: EXCEPTIONAL TOP 10: OffOPENESS/CHANGE: N/A: OffOPENESS TO LEARNING/CAPACITY TO CHANGE TEXT: ACCEPT FEEDBACK: BELOW AVERAGE BOTTOM 50: OffACCEPT FEEDBACK: AVERAGE TOP 40: OffACCEPT FEEDBACK: GOOD TOP 30: OffACCEPT FEEDBACK: SUPERIOR TOP 20: OffACCEPT FEEDBACK: EXCEPTIONAL TOP 10: OffACCEPT FEEDBACK: N/A: OffABILITY TO ACCEPT CONSTRUTIVE FEEDBACK TEXT: INTEGRITY/HONESTY: BELOW AVERAGE BOTTOM 50: OffINTEGRITY/HONESTY: AVERAGE TOP 40: OffINTEGRITY/HONESTY: GOOD TOP 30: OffINTEGRITY/HONESTY: SUPERIOR TOP 20: OffINTEGRITY/HONESTY: EXCEPTIONAL TOP 10: OffINTEGRITY/HONESTY: N/A: OffINTEGRITY/HONESTY TEXT: SOUNDS JUDGEMENTS: BELOW AVERAGE BOTTOM 50: OffSOUND JUDGEMENTS: AVERAGE TOP 40: OffSOUND JUDGEMENTS: GOOD TOP 30: OffSOUND JUDGEMENTS: SUPERIOR TOP 20: OffSOUND JUDGEMENTS: EXCEPTIONAL TOP 10: OffSOUND JUDGEMENTS: N/A: OffABILITY TO MAKE SOUND JUDGEMENTS TEXT: EFFECTIVENESS CULTURALLY DIFFERENT: BELOW AVERAGE BOTTOM 50: OffEFFECTIVENESS CULTURALLY DIFFERENT: AVERAGE TOP 40: OffEFFECTIVENESS CULTURALLY DIFFERENT: GOOD TOP 30: OffEFFECTIVENESS CULTURALLY DIFFERENT: SUPERIOR TOP 20: OffEFFECTIVENESS CULTURALLY DIFFERENT: EXCEPTIONAL TOP 10: OffEFFECTIVENESS CULTURALLY DIFFERENT: N/A: OffEFFECTIVENESS WORKING WITH CULTURALLY DIFFERENT I/G TEXT: HIGHLY RECOMMEND: OffRECOMMEND: OffNOT SUITED FOR PROGRAM: OffElementary Statistics Course Verified: OffRésumé: OffThree School of Social Work MSW Reference Forms: OffAFRICAN AMERICAN/OTHER BLACK: OffAMERICAN INDIAN/NATIVE AMERICAN: OffASIAN AMERICAN/OTHER ASIAN: OffCHICANO/MEXICANAMERICAN: OffOTHER LATINO(A)/HISPANIC: OffPACIFIC ISLANDER/NATIVE HAWAIIAN: OffWHITE/CAUCASIAN: OffMULTIPLE RACE/ETHNICITY: OffPUPIL PERSONNEL SERVICES CREDENTIAL (PPSC): OffSTATS APPROVED YES: OffREFERENCE #1 ACADEMIC: OffPROFESSIONAL/GRADUATE STUDENT FAIR: OffWAIVE RIGHT: OffDO NOT WAIVE RIGHT: OffACADEMIC ADVISOR: OffRELATIONSHIP WITH PEERS: EXCEPTIONAL TOP 10: OffRELATIONSHIP WITH PEERS N/A: OffKP Mental Health Scholar: OffAPPLICANT INITIALS/DATE: