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These need to relate to the learner objectives and therefore to specific course work. Number of credits to be earned. Number of hours required on site. Number of meetings required with the faculty member supervising the internship. Name of and responsibilities of on-site supervisor. How the performance of the student will be assessed by the on-site supervisor. How the performance of the student will be assessed by the faculty member. Number of Credits: Grade Mode: ( Normal Letter ( Credit/No Credit ( S/U Schedule Type: ( I (not part of teaching load) ( J (part of teaching load) Credit Applied To: ( Major ( Cognate ( General Education ( Free Name/Location of Employing Agency: _________________________________________ On-site Supervisor:______________________________________ ______________________________________ (Signature (Title) Faculty Member: ____________________________ ____________________________________ (Signature) Date Student: ____________________________________ ___________________________ (Signature) Date  APPROVALS: Agency Affiliation Agreement signed by: ______________________________________ Program Director: ____________________________ ___________________________ (if applicable) (Signature) Date Department Chair: ___________________________ ___________________________ (Signature) Date Students Dean :_____________________________ ___________________________ (Signature) Date Actual conferral of credits depends upon satisfactory completion of the conditions of the internship. 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