Site Supervisor Verification Form- Summer/Fall 2024

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Internship / Independent Study

Email *

Directions: Please complete this brief google form and read the included COVID19 Expectations for Clinical Practicum and Internship/Externship information to verify you will be supervising a student from UMD Department of Kinesiology for an internship or independent study/ research experience. Form must be submitted, no later than the beginning of schedule adjustment period for the corresponding semester.

If you have questions, please feel free to contact one of the KNES Internships Coordinators: Dr. Betty Brown - ebrown2@umd.edu (301) 405-2503 or Dr. Joanne Klossner - jklossne@umd.edu (301) 405-2569

Please access the Expectations for Clinical Practicum and Internship/Externship information document by clicking on this link below. While this document was generated during the Covid 19 Pandemic, it emphasizes the need for proper health safety practices for the student as well as the clinical placement site. https://drive.google.com/file/d/1li06ii5Phn2E9GLFqmH_PIiQMh3GJXTq/view?usp=sharing *

I have read the Clinical Practicum Expectations Document provided.

First name of student completing internship with you. *

Last name of student completing internship with you. *

Semester student will complete internship with you. *

Summer

Fall

Your name and credentials (if relevant) *

Name of Organization / Site Name *

What is your phone number? *

Site Address (including general site email) *

Students register for credit hour hours based on contact hours with the internship/ independent study). Approximately how many internship hours will the student complete under your supervision? *

45 contact hours (1 credit)

90 contact hours (2 credits)

135 contact hours (3 credits)

Unsure at this time

Please BRIEFLY list general duties and expectations of the student while participating in this internship. If repeated internship for the student, please verify that duties will expand about student's previous experience. *

May we save information about this internship in our student internship database? *

Yes, you may include my contact information as well as internship site details

Yes, you may include internship site details only. Please don't include my contact information.

Not at this time.

Thank you for completing this form. By selecting "Yes" below and submitting this form, you will be verifying that the above named student will be completing an internship under your supervision and that you have read the Expectations for Clinical Practicum and Internship/Externship . We appreciate your willingness to provide this professional development opportunity for a Department of Kinesiology student from the University of Maryland! *

YES

Send me a copy of my responses.

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