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Stipend Application
Social Work Opioid Work Force Grant

Questions marked with a * are required
Which semester will you be starting your Advanced Graduate Specialty Split Field Placement for Social Work?
This is an application for a $10,000 stipend. It is available to UTA MSW students in the MH/SA specialization to help with expenses during field placement.  The primary aim of this program is to train you to work with substance use disorders, with emphasis on opioid use disorders.  We plan to award up to 14 stipends to students each Spring and each Fall (now though 2022). *This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number T98HP33478, Opioid Workforce Expansion Program-Professional.

To qualify for this stipend/training, you must have an interest in working with opioid use disorders, and....
  • be a MSW student in the UTA School of Social Work, applying for your Advanced field placement;
  • your concentration must be Mental Health/Substance Abuse (MH/SA);
  • complete a split (2 semester) placement and log 250 hours each semester;
  • have some flexibility with your schedule to be able to intern the hours most conducive to agency schedules to work with SUD;
  • sign up for a special training course as an UTA elective : SOCW 5392 which is offered Monday afternoons;
  • attend an all-day UTA Substance Use Symposium, occurring during the Spring semester;
  • participate in at least 2 Inter-professional trainings / events;
  • able to intern at a location selected for you and work the hours the placement requires.
If you have questions about this application, please email sherry.bobo@uta.edu.
Based on these criteria, do you qualify for this stipend?
First Name
Last Name
MAVS Student ID number
What is your gender?
Are you of Hispanic, Spanish, or Latino descent (select all that apply)?
Choose one or more races that you consider yourself to be:
What is the highest grade, or level of school, that your father completed?
What is the highest grade, or level of school, that your mother completed?
Undergraduate Degree
Other Degrees - Type N/A, if none
If you receive Financial Assistance with your Free Application for Federal Student Aid (FAFSA) application, what portion are you responsible for  (financial aid eligibility, not including GI Bill)?          
Unmet Need Amount - Put "0" if none or does not apply
What is your current (MSW) GPA (4.0 Scale).
GPA
What was your undergraduate GPA (4.0 Scale).
GPA
Current Street Address, please include apt #
City
State
Zip code
What is your permanent mailing address? (Address where you can receive mail - up to 2 years Post-Graduation)
Street Address Line include apt #
City
State
Zip code
What is your MAVS email address?
What is your personal email address?  (NOTE:  Because this is a research study, we will need to email you to gather follow-up information up to 2 years post graduation.  Please provide your permanent email address)
Personal Email Address
Cell Phone Number or best contact number
We may contact you for up to 2 years post-graduation.  What is an alternative number where you could be reached?
Enter alternate number, such as a home phone, parent or partner phone
Veteran Status
Are you a member of a health disparities group?  Please check all that apply:
List any other languages in which you can converse.
I am b
i-lingual or multi-lingual in the following. If English is your only language, put N/A
What is your citizenship status?
Is your residence of origin a MH/HPSA? Please use the following link to determine the answer.  MAKE SURE YOU RIGHT-CLICK AND OPEN THIS LINK IN A NEW TAB OR WINDOW OR LEAVING THIS PAGE MAY FORCE YOU TO START OVER. 
https://data.hrsa.gov/tools/shortage-area/hpsa-find 
Select your home state and county, then under "Filters", uncheck "Primary Care" and "Dental Health" so that "Mental Health" is the only filter.  Submit the form then look under the column that is labeled "HPSA Score".  Record the lowest number and the highest number below.   

Lowest number
Highest number
If you had a score above to MH/HPSA question, specify location (county and state).


 
An NPI number is a National Provider Identifier that is required of all HIPAA-covered who bill Medicare for services.  The funder of this stipend recommends that all healthcare providers who work with substance use disorders apply for an NPI.  
MAKE SURE YOU RIGHT-CLICK AND OPEN THIS LINK IN A NEW TAB OR WINDOW OR LEAVING THIS PAGE MAY FORCE YOU TO START OVER. 
Upon graduation, do you intend to apply for a National Provider Identifier number?
What is your current year in the MSW program (number of consecutive years you have been enrolled as an MSW graduate student)?
Are you a full-time MSW student at UTA?
What is your MSW program admission status?
If you are selected to receive this stipend, you understand that it will be paid directly to you - $5,000 in the middle of semester 1 and $5,000 in the middle of semester 2 of your internship. This means you will not be able to use the stipend to pay tuition at the beginning of semester 1, because tuition is due before you receive the stipend.  You may, if you choose, save the money from the 1st payment of the stipend to pay for tuition of semester 2.
My selected specialization is Direct Practice in Mental Health and Substance Abuse.
Upon graduation, do you intend to seek employment in a mental health and substance abuse setting with social work supervision that will meet criteria for application for the LCSW after two years equivalent of supervised practice at the LMSW level?
Is your schedule flexible, such that you can work whatever hours required by the field placement?  (This may include daytime hours, Saturday hours and possibly 2 evenings per week)
I understand that if selected, I am required to take an elective that was designed specifically for stipend recipients. It provides specialized training in substance use disorders with an emphasis on opioid use disorders.  I am responsible for paying for this 3-hour course :: SOCW 5392.  I must sign up for this elective even if I have already taken the electives I need to graduate.
I understand that if selected for this stipend, I must attend an all-day Symposium on Opioid Use Disorders. It is typically offered once a year.  These symposium hours count toward the total internship hours required during field placement. 
Please select as many statements from this list that match your post-graduation intentions:
Please provide any clarification for your answers above, including specific limits on availability.
Are you able to be mobile after graduation in order to meet your employment obligations?
Are you interested in working with groups experiencing health disparities (Check all that apply):
I understand that if selected for this stipend, I agree to respond to survey questions about this experience and my current employment for up to two years post graduation.
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