| Name of student:
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| Internship organization:
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| Internship supervisor:
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| Credit hours:
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| Dates of internship:
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| Internship description: 1. Problem to be solved or task to be completed:
2. Research to be conducted:
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| Nature of final portfolio and report:
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| Basis for determining grade:
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| We approve this internship:
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| Student/Date:
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| Internship supervisor/Date:
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| Program Committe chair/Date:
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| Program Committee member/Date:
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| Program Committee member/Date:
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| Director of Graduate Studies/Date:
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Please sign legibly.