Palliative Care Clinical Social Work Fellowship Program Application

University of Minnesota Medical Center, Fairview

Transitions and Life Choices Palliative Care Program

Instructions:

Complete application and submit it along with the following items:

1. Current resume/curriculum vitae

2. Copy of current state social work license (Students currently completing their MSW degree should send proof of passing the licensure exam in lieu of a current license.)

3. Three to five letters of reference. At least two should be from clinical supervisors (may include clinical, not BSW or foundation, field placement supervisor). It is preferred that at least one be from a member of an interdisciplinary team member with whom you have worked.)

4. Copy of MSW field placement evaluation from clinical/second placement (MSW students currently in an internship can use their mid-year evaluation.)

5. Official graduate school/MSW program transcript

6. Two to three page (maximum) professional statement that includes your experience and interest in palliative care, your reason(s) for applying for this fellowship, your learning goals, any special interests you would hope to pursue in the fellowship, preliminary thoughts on a focus for a clinical project, and your future plans and goals for using the knowledge and experience gained from the fellowship

Name: ____________________________________________________________________

Address: __________________________________________________________________

Home Phone: ____________________________ Work Phone: ______________________

Cell Phone: ______________________________ Email: ___________________________

Undergraduate Education:

College/University:

Degree:

Year of Graduation:

Major:

Graduate Education:

College/University:

Degree:

Year of Graduation:

Concentration:

CSWE Approved: Yes _____ No _____

Master’s Thesis Title (if applicable):

Field Placements:

BSW/MSW Foundation:

Agency:

Brief Description of Practice:

MSW Clinical/Second:

Agency:

Brief Description of Practice:

Honors/Awards/Honorary Societies (if not included in resume/c.v.):

Participation in Social Work Research (if not included in resume/c.v.):

Social Work Licensure:

State: Serial Number:

Date of Issue: Expiration Date:

If not yet licensed, date of licensure exam: __________ Passed/Failed: _________

Have you ever been convicted of a crime other than a traffic violation?

Yes _____ No_____

If yes, please state each crime, date of conviction, and court:

I declare that the information contained in this application is correct and complete to the best of my knowledge. I understand that Fairview Health Services may request additional information from any of the institutions I have named above regarding my candidacy. I understand that misrepresentation of facts in this application process will be cause for rejection of the application or termination after training begins.

Signature: __________________________________ Date: _______________________

Application packet and any other correspondence should be addressed to:

Dot Landis, ACSW, LICSW

University of Minnesota Medical Center

MMC # 181

420 Delaware Street SE

Minneapolis MN 55455

Telephone: 612-273-5893

Email: dlandis1@fairview.org