RHS Internship Scheduling Sheet (Appendix A)
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 _________________