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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: [email protected]. 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 [email protected] email
account.
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http://www.csulb.edu/colleges/chhs/departments/social-work/master-of-social-work/
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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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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 [email protected].
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:[email protected]
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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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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
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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
[email protected] 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
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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:
[email protected]. 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 [email protected] 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
[email protected]. 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 [email protected]
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 [email protected] 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: