Student Name:_____________________________________                           ID#:________________ 

Campus address:___________________________________                         Phone:_______________

Employer/Company Name:____________________________________________________________

Address:____________________________________________________________________________

Phone:________________________                           Email:___________________________________

Internship Site Supervisor’s Name and Title:_________________________________________________

Course Information - Internship/Field Experience/Independent Study (*Where applicable by department/major):

Course name and number*:_________________________________________________________________

Semester/Year enrolled:__________________________________ 

Internship Start Date:______________        End Date:_____________             Hours/Week:___________

Step 1:   List learning goals and (2) objectives -  

(Consider theoretical issues, problems, and/or relationships of academic and internship experience)

1: _______________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

2: ________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Step 2:   Describe your internship duties and responsibilities (attach a formal job description if available).

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Step 3:   Contact the faculty member in your major who has agreed to sponsor you to set up an appointment

to discuss your goals and objectives and to complete this proposal form. 

__________________________________________________________________________________________

__________________________________________________________________________________________

Step 4:   Discuss number of credits to be earned (1 – XX)                        Number of credits:______________ 

Step 5:   Discuss course requirements to be assigned for successful completion of the experience. 

Examples are listed below.  Be specific about requirements and due dates. 

Assignment                                                          Explanation                                                    Due Date

Examples of work performed:_______________________________________________         ______________

_______________________________________________________________________

Reading assignments:______________________________________________________        ______________

_______________________________________________________________________         

Reports on readings:_______________________________________________________        ______________

_______________________________________________________________________

Progress Reports/Evaluations:_______________________________________________         ______________

_______________________________________________________________________

Journal:_________________________________________________________________          ______________

_______________________________________________________________________

Research Topic and Paper:__________________________________________________         ______________

_______________________________________________________________________

Demonstration of competencies obtained:______________________________________         ______________

_______________________________________________________________________

Class Presentation:________________________________________________________          ______________

________________________________________________________________________

Final written/oral report:____________________________________________________          ______________

________________________________________________________________________

Grading Criteria: Grading for the internship will be based on the following:

_________________________________________________________________________________________

_________________________________________________________________________________________

_______________________________________________________________________________

Signatures:                                                                                                                                           Date

Student:________________________________________________________________            ______________

Site Supervisor:__________________________________________________________           ______________

Print name of supervisor:___________________________________________________

Faculty Sponsor:_________________________________________________________            ______________

Print name of faculty sponsor:_______________________________________________

Academic Advisor:_______________________________________________________             ______________

Print name of academic advisor:_____________________________________________

Dean/Department Chair:__________________________________________________            ______________