RHS Internship Scheduling Sheet (Appendix A)

Submit to RHS Administrative Assistant                                            Internship Approved ______
125 CEDAR Building                                                                          Number of Credits   ______
University Park, PA 16802

Intern Information:

Student name ____________________________                         Student PSU ID# _____________

Student address during internship (not site address)

Phone # _______________               PSU email _________________            Non-psu email _____________

Semester & year of internship (RHS 495A) _____________

Student has met all requirement except internship credits _____________

RHS Faculty Advisor’s initials  ___________       College of Ed. Academic Advisor’s initials __________         

Internship Site Information:

Supervisor name (Dr., Mr., Ms.) ____________________________________

Agency/Facility Name ____________________________________________

Agency/Facility Address (full address including zip code)

County located ____________________                                     Population Served _____________________

Site supervisor phone # _____________                                     Site supervisor email ___________________

Accreditation or Licensure (e.g., CARF, JCAH, PARG, M.A.) ______________________________________

Are you required to carry malpractice/liability insurance?                                             Yes ____  No ____
Are you required to have a recent criminal background check?                                    Yes  ____ No ____
Are you required to have a child abuse clearance?                                                       Yes ____  No ____
Are you required to have memorandum of understanding
or an affiliation agreement with Penn State?                                                                  Yes ____ No ____

Student signature ________________________________________________     Date _________________