The Externship-Internship

The term Externship-Internship" refers to a supervised educational work experience with an approved health or wellness service agency, organization or institution. Participation in an internship allows the student to develop and mature through work experience under the guidance of trained and established professionals in the field.
In addition, the Externship-Internship is an extension of the curriculum. The Externship/Internship experience affords the student an opportunity to apply his/her theoretical knowledge and technical skills in a practical manner, gaining valuable pre-professional and in-service training. The Externship-Internship experience will enable students to perform with a higher level of skill and confidence.

The following are examples of acceptable internship sites:
A Clinical Internship: Examples include working in a physician's or another credentialed nutritionist's office; i.e. Naturopathic Physician, Chiropractor, Osteopath, Acupuncturist. However, the internship will be accepted only if nutrition is part of their practice.
A Spa or Health Club Internship: Examples include helping customers with their weight, lifestyle and exercise programs.

A Worksite Wellness Internship: An example would be working in a business that has a Wellness or Fitness function within the Human Resources Department educating employees how to live a healthier lifestyle.
A Vitamin or Retail Store: An example would be working in the supplement section of a grocery store assisting customers with their nutritional supplement selection or conducting seminars and contributing articles for the store’s educational newsletter.

Purpose of the Externship-Internship Program

The basic purpose of the Externship- Internship is to provide a planned transition from the IAHS/AHSU/NINE curriculum to a professional health setting. Throughout the Externship-Internship, the Extern/Intern student will test the practical application of the theories of Nutritional Counseling in the agency setting under the guidance and supervision of an agency professional. As part of the leadership experience, the Agency Supervisor evaluates the Intern. In addition, he/she continually reviews his/her own knowledge, skills, accomplishments and professional growth as they apply to this preparation for entry into the health and/or wellness service professions.

Basic Objectives of the Externship-Internship Program:

To provide the Extern/Intern the opportunity to integrate theory and practice into his/her professional education and to encourage the exchange of contemporary thinking between the Externship-Internship and agency professional.
To provide the Extern/Intern an opportunity to promote and broaden his/her philosophy and understanding of the health professions.
To enable the Extern/Intern to obtain information which can be used as a basis for making choices in relation to future careers, areas of specialization and/or further study.
To enable the Extern/Intern to realize his/her own strengths and weaknesses.
To provide the Extern/Intern an opportunity to gain experience in leadership, supervisory and administrative functions.
To help the Extern/Intern gain an understanding and appreciation of the role, duties and responsibilities of a full-time professional.
To develop the Extern/Intern's skills in various program areas and to increase his/her knowledge of the organization and administration of health services.
To provide the Extern/Intern with experiences that will enable him/her to develop sound human relations during client/customer interactions.
To help the Extern/Intern develop his/her oral and written communication skills.

Externship-Internship Eligibility Requirements

Must be a student in the CN Program and have completed the Course 4 midterm, BIO 410.
The student must be accepted by an agency and the Verification of Externship/Internship Placement (Form B) and the Hold Harmless Agreement (Form C) must be submitted to AHSU/NINE to confirm final placement.
Interns must complete 150 hours.
The Internship may be completed at any agreed upon hours, convenient to the intern and the agency.

Procedure for the Externship-Internship Program

Read the Externshipp-Internship Manual.
Locate an agency (or agencies).
Prepare and send a copy of your resume (see Appendix, Form A) to IAHS/AHSU/NINE.
Make an appointment for an interview with the agency. Take with you the Supervisor’s Manual, your resume, and the Verification of Externship- Internship Placement form (Form B).
If you and the supervisor mutually agree on placement in the agency, the "Verification of Internship Placement" (Form B) and the “Hold Harmless Agreement” (Form C) must be returned to the IAHS/AHSU/NINE Externship-Internship Coordinator by mail before the Externship-Internship will commence.
Follow the "Externshhip-Internship Outline and Requirements" (on the following page) as an aid for completing theExternship-Internship program. Pay particular attention to the forms and evaluations that must be completed by both you and your agency supervisor.

Externship- Internship Outline and Requirements

Important Dates and Assignments

Assignment Due Date

Prepare and submit a copy of your resume.       (Form A)                                                                 Prior to start
Take Supervisor’s Manual, a copy or your resume, and the Verification of Externship-Internship Placement Form (Form B) with you when interviewing for Externship-Internship position.
Complete and return Verification of Externship-Internship Placement (Forms B)                      Prior to start
Complete and return the Hold Harmless Agreement (Form C)                                                     Prior to start
Return Intern Contract (Form D) to AHSU/NINE Externship- Internship Coordinator Prior to start

Complete and return Intern-Agency Contract (Form E)                                                                     End of 1st week
Complete and return Preliminary Student Performance Eval (Form F)                                         End of 2nd week
Complete and return MIDTERM Student Performance Appraisal (Form G)                                 After 75 hours
Weekly Activity Reports, (Form H)                                                                                                         Submit Monthly
Complete and return FINAL Student Performance Appraisal (Form I)                                          Last week of Int.
Extern/Intern’s Summarization Report (Form J)                                                                              Upon completion
Extern/Intern Evaluation of Externship-Internship Site (Form K)                                                    Upon completion

Important Note:
It is the student’s responsibility to make sure that appropriate forms and evaluations are completed and returned to IAHS/AHSU/NINE on time. Copies of all forms that the Agency Supervisor and the student have to complete are located in the back of this manual. Be sure to set up appointments in advance to complete these forms (Performance Evaluations, etc.) to ensure that they are completed at the appropriate time during your internship. Send these forms toIAHS/AHSU/NINE on behalf of the Supervisor to minimize time constraints on the Supervisor.

Grading Policy
The Extern/Intern must complete the required 150 hours to successfully pass the Externship- Internship Program. The Extern/Intern will receive a “Certificate of Completion” for successfully completing theExternship-Internship program. Students who fail to complete the required 150 hours will receive a failing grade and remain unlicensed until they have completed the program.

General Policies of the Externship-Internship Program

If the Extern/Intern is currently employed by an agency that practices integrative healthcare, the Extern/Intern may apply to waive their internship hours. Please contact IAHS/AHSU/NINE for an Externship/Internship Waiver Request Form. Once the Waiver Request Form is reviewed, the Externship-Internship Coordinator will determine whether to waive all or half of the Externship/Internship hours. The Extern/Intern will be notified of this decision by mail.

Agency Related:

Some agencies do offer paid Externship-Internship programs. If this is the type of program the Extern/Intern is interested in obtaining, it is the Extern/Intern’s responsibility to make the necessary inquiries prior to accepting an internship position.

The Extern/Intern may be covered by the agency's liability insurance. The Extern/Intern should document in writing the agency's requirement and submit it to the Externship- Internship Coordinator at least one month prior to the initiation of the Externship-Internship.

Liability Insurance Information
If liability insurance will not be provided by the agency, it is suggested that the student obtain professional liability through outside sources. IAHS/AHSU/NINE does not require the student to obtain professional liability insurance, but the agency may require the student to obtain such insurance. Information for liability insurance may be found through HPSO, Healthcare Provider Service Organization, at www.hpso.com or calling 1-800-982-9491(under Wellness Counselor) or Marsh Affinity Group at www.proliability.com or 1-800-530-9230.

Regardless of whether the student obtains liability insurance or not, AHSU/NINE requires that both the student and the agency supervisor sign a Hold Harmless Agreement found in the Student’s Internship Manual (Form C) releasing AHSU/NINE from any liability regarding a student’s actions during such internship. It is mandatory that this form is signed and returned to the AHSU/NINE office prior to the student commencing the internship.

Intern’s Responsibilities

To conform with regulations pertaining to the agency staff.
To plan in advance for all assignments.
To do the best possible job in carrying out all assignments.
To evaluate each meeting or activity that he/she has planned and/or conducted.
To prepare for periodic Agency Supervisor and Internship Student conferences; ask questions and present constructive ideas if requested.
To be well groomed and appropriately dressed.
To notify the Agency Supervisor well in advance in cases of absence from work.
To accept the agency's philosophy, methods, leadership and program.
To be tactful, friendly, courteous and respectful to all.
To be cheerful and offer praise to others for good work.
To consult with the Agency Supervisor when confronted with problems he/she cannot satisfactorily solve by himself/herself.
To consider himself/herself a co-worker of the agency staff.
To complete assignments and responsibilities as outlined in the "Intern-Agency Contract" (see Appendix, Form E).
To complete the Intern Contract (See Appendix, Form D) and the Hold Harmless Agreement (Form C) and return them to the AHSU/NINE Internship Coordinator prior to commencement of internship.
To complete the "Intern-Agency Contract” along with the Agency Supervisor during the first week of service (see Appendix, Form E) and return it to AHSU/NINE prior to commencement of internship.
To submit to the Agency Supervisor the Intern's own goals and objectives while with the agency.
To complete a "Weekly Activity Report” (see Appendix, Form H) each week, which are submitted to AHSU/NINE at the completion of each month of the internship.
To submit upon completion of the program any outstanding “Weekly Activity Reports,” the "Intern Summarization Report" and the "Intern’s Evaluation of Internship Site" (see Appendix, Forms H, J, and K respectively).
To complete assignments and responsibilities as outlined in the "Intern-Agency Contract" (see Appendix, Form E).
If the Internship Student intends to terminate his/her Internship site, notification must be forwarded to the AHSU/NINE Internship in writing.

Agency’s Responsibilities

To cooperate in the exchange of information about the Intern.
To evaluate Internship experiences and practices, offering recommendations for improvement to the intern.
To complete the "Preliminary Student Performance Evaluation" during the second week of the Internship (see Appendix, Form F) to be signed by the Agency Supervisor and the Intern and then forwarded to AHSU/NINE Internship Coordinator.
To complete the "Student Performance Appraisal-Midterm" (after the intern has completed 75 hours). After reviewing it with the Intern (see Appendix, Form G) it must be signed by the Agency Supervisor and the Intern and then forwarded to the AHSU/NINE Internship Coordinator.
To complete the final "Student Performance Appraisal-Final" (one week prior to Internship's End). After reviewing it with the Intern (see Appendix, Form I) it must be signed by the Agency Supervisor and the Intern and then forwarded to the AHSU/NINE Internship Coordinator.
To confer with the Intern to determine his/her responsibilities during the experience and to present an overview of the agency's purposes, policies, administration, program and facilities.
To inform the Intern of all regulations to which he/she must conform.
To introduce the Intern gradually into the Internship experience, beginning with observations and minor duties and adding more responsibilities as the Intern’s ability permits.
To acquaint the Intern with resources and materials used in the administration of the program such as books, pamphlets, films, charts, etc.
To become acquainted with the "Training Guide Outline" (located in both the Intern and Supervisor Manuals) and discuss those as well as other appropriate topics with the Intern regularly during scheduled meetings.
To encourage the high standards and to praise the Intern for work well done.
To provide the Intern with successful sequential experiences that will promote growth and achievement.
To present critical evaluations in a constructive, objective and tactful manner.
To recognize that the Intern is in the process of learning and not to expect performance comparable to full-time staff members.
To encourage self-evaluation by the Intern.

Internship Program Job Description

Informs the Intern what is specifically expected of him/her by developing a performance contract.
Adequately orients the Intern to the agency, his/her co-workers and the job.
Assigns the Intern responsibilities, which will challenge his/her creativity.
Anticipates possible problems and immediately takes steps to prevent their development.
Advises the Intern of deficiencies in initiative, enthusiasm, skills, knowledge, leadership and interpersonal relationships.
Follows evaluations with discussions in which the Intern is made aware of his/her strengths and the areas in which he/she needs improvement.
Gives the Intern every opportunity to mature professionally through carefully planned Internship experiences.
Communicates on a regular basis with the Intern. The minimum number of meetings an Agency Supervisor is expected to have is one per week (if the intern’s weekly hours are less than 20 hours per week, one meeting every two weeks is sufficient).

Training Guide Outline
The Agency Supervisor and Intern should meet on a regular basis to discuss topics and exchange information. During these discussions the student can learn about other aspects of agency operation and its problems. The following are suggested topics for discussion and may or may not be appropriate for different agencies.

A.       Orientation
          1. General information about the community and the agency
          2. Specific information regarding agency organization
          3. Introduction to agency personnel
          4. Job orientation and work schedules
          5. Tour of the agency areas and facilities
          6. Professional etiquette
          7. General information about the agency's services
          8. Plan for the Internship assignment
          9. General philosophy of the agency
        10. Goals and objectives of the agency

B.        General Administration
         1. Organization of the board or governing authority
               a. Board policies and operational procedures
               b. Board of officers and their responsibilities

         2. Agency organization
              a. Line-staff relationships
              b. Personnel operations and policies
                  1) Job analysis and assignment of duties
                  2) Selection of employees
                  3) Evaluation of personnel
                  4) Salaries and fringe benefits
                  5) Dress code

           c. In-service training programs
           d. Office procedures
                1) Office operations
                2) Records and reports
                3) Filing systems

           e. Use of Volunteers
                1) Selection process
                2) Training procedures
                3) Assignment of responsibilities

Suggested Resume Outline Form A

Name
Address, telephone number, and e-mail address (make sure the e-mail address is appropriate. Superwoman@hotmail.com may give the wrong impression to potential employers)
Education (list most recent first)
Graduate study
College
Experience (paid and voluntary)
Professional endeavors (workshops, conferences, etc. - dates, titles or explanations and locations)
Special activities and honors

List any abilities that merit mentioning (special training/talent)

Hobbies
Sports
Interests
Travel experience
Certificates/registrations (e.g., WSI, CPR, etc.)

Professional Affiliations (Memberships)
Publications
Miscellaneous

Note: Resume should be typed, neat, clear, and concise. It is recommended that the resume be one page in length. It is not necessary to include an objective.

Verification of Internship Placement Form B

After Interview, Mail this to:
AHSU/NINE Internship Coordinator, Internship Program
American Health Science University/NINE
1010 S. Joliet, Suite 107
Aurora, CO 80012

Student Intern: __________________________________________________________________

Date of interview: _______________________________________________________________

An interview has been completed with this student.

_________ We will consider this student for an Internship placement

_________ We will not consider this student for an Internship placement

If not accepted, please state reasons:

Interviewer: _____________________________________________________________________

Title: __________________________________________________________________________

Agency: ________________________________________________________________________

Address: _______________________________________________________________________

Phone: _________________________________________________________________________

E-mail address: __________________________________________________________________

Hold Harmless Agreement Form C

I, ________________________, a student of American Health Science University/NINE

will be working as a student intern at _________________________________________

under the supervision of ___________________________________________ beginning

__________________________________. I understand that the activities I engage in at
Beginning date of internship
______________________________________________ will be for my educational benefit
Name of Agency
and that, at no time, should I be acting as a practicing nutritionist. I understand that my

actions during the internship are solely my own and hold harmless American Health

Science University/NINE for any of my actions as an internship student.

___________________________ __________________________
Student Intern (Please print) Signature of Student Intern

Dated this ______ day of ____________, 20____.

===============================================================================

I have read the above Hold Harmless agreement and understand that the actions of the above student while working as a student intern in the above agency are his/her own and that American Health Science/NINE is in no way responsible for the actions of the student intern.

___________________________ ___________________________
Agency Supervisor (Please print) Signature of Agency Supervisor

____________________________ ___________________________
Name of Agency Title of Agency Supervisor

Dated this ______ day of ______________, 20____.

===============================================================================

Received in the American Health Science University/NINE office on

________________, 20____ By ____________________________________

Intern Contract (to AHSU/NINE) Form D

The following contractual items between _______________________________ and American

Health Science University/NINE, dated this _____ day of ________, _____ constitutes a binding
Contract for an Internship to be completed at ___________________________________ for a
total of 150 hours.

Contract Terms
The Intern will:

Purchase the Internship Manual and be responsible for reading and demonstrating the knowledge of its contents with his/her Agency Supervisor as well as with AHSU/NINE.
Submit all materials on time and in legible form.
Complete the "Weekly Activity Report" (see Appendix, Form H) and have it signed by the Agency Supervisor each week. The intern will submit all Weekly Activity Reports monthly to the AHSU/NINE Internship Coordinator.
Review each of your "Student Performance Appraisals" with the Agency Supervisor (should be completed by the Agency Supervisor after completion of 75 Internship Hours and one week prior to completion of the Internship).
Arrange periodic conferences with the Agency Supervisor. Conferences should be held at least one time per week and should be at a regularly scheduled time (if internship hours are less then 20 hours per week, then one conference every two weeks is sufficient).
Discuss with the Agency Supervisor, in conferences, the items suggested in the "Training Guide Outline." Include the subsequent information gathered along with other appropriate materials including Weekly Activity Reports and final evaluations of the internship site and submit to the Internship Coordinator.
Adhere to all policies, regulations, procedures and assignment dates as explained in the Internship Manual.

I hereby acknowledge that the items explained in this contact constitute a binding agreement for an educational experience between the Intern and AHSU/NINE Internship Coordinator. The grade received for the internship will be based on the aforementioned items.

Intern Signature _________________________________________ Date ____________________

Intern-Agency Contract* Form E

The following contractual items between ______________________________________ and
Intern’s Name
_________________________________, of ___________________________________,
Agency Supervisor Agency Name
discussed and agreed upon this _____ day of ________, _____ constitutes a binding contract
for the internship experience of 150 hours.

Policies regarding Internship
I. Regarding the agency relationship with the American Health Science University/NINE.

Complete the "Preliminary Student Performance Evaluation" (see Appendix, Form F)
Complete the "Midterm Student Performance Appraisal" after the Intern has completed 75 total internship hours (see Appendix, Form G)
Complete a conference with the Internship Student no less than 1 time per week (or 1 every two weeks if weekly hours are 20 hours or less).
Complete the "Final Student Performance Appraisal" one week prior to internship's end; see Appendix, Form I)
Regarding the status of the AHSU/NINE Internship Student at _______________________

Agency Name

Is classified as an "Internship Student".
Has the status of a professional staff member and awarded such rights and privileges.
Attends all staff meetings and applicable committee and board meetings; works to uphold the character and image of the agency.
Philosophy of agency in regard to Intern:

The Agency agrees:
1.   That the personal growth and development of the Intern is the primary concern of the agency in       participation in this program.
2.   To work towards improvement in the Intern’s administrative, program and personal areas to instill        professional confidence and competence.
3.   That gains by the agency in supervision and/or savings in leadership expense cannot be        motivation for participation in this program.
4.   That requirements by AHSU/NINE will be adhered to and in cases in which disagreements arise        in regards to principles, practices and philosophies of the agency. A satisfactory solution will be        determined in consultation with the AHSU/NINE Internship Coordinator, the Intern and the Agency        Supervisor.
5.   That all professional staff and other applicable employees are asked to assist the Intern with the        completion of all contractual items.

Requirements of the Intern

The Intern:

Will work the number of weeks required to complete 150 hours, beginning

(Date) _________for a maximum of _______ hours per week.

However, consideration will be given to the intern’s family life and personal needs in
the assignment of hours.

Will strive for understanding the total agency operation through discussion, observation and evaluation.
Will specifically be responsible for all activities and responsibilities as outlined by the agency, including projects, duties, etc.

Realizing this is a contractual guide and not a binding legal document, we agree to work together towards its satisfactory completion for the mutual benefit of all concerned.
Intern_________________________________________________ Date: __________________

Agency Supervisor _______________________________________ Date: __________________

Date Received: ________________ AHSU/NINE Internship Coordinator: ____________________

Preliminary Student Performance Evaluation Form F

To be completed by the Agency Supervisor, reviewed with the Intern and returned to AHSU/NINE.
To be completed during week two of placement.

Date: __________________

Intern’s Name: _________________________________________________________________

Agency: ________________________________________ Phone #: ______________________

Agency's Address: ______________________________________________________________

Please comment briefly on the following:
(Attach additional pages if necessary)

Attitude:

Awareness and preparation for Internship:

Appearance:

Appropriate placement: _____Yes _____No

Agency Supervisor's Signature: ____________________________________________________

Intern's Signature: _______________________________________________________________

Date Received: ________________ AHSU/NINE Internship Coordinator Signature: __________

Student Performance Appraisal-Midterm Form G
To be completed as a Mid-Term Analysis after 75 hours.
Internship Student's Name: ________________________________________________________

Agency: _______________________________________________________________________

Agency Supervisor: ______________________________________________________________

Please rate the Intern in each of the areas that follow and forward this appraisal to the AHSU/NINE Internship Coordinator at mid-term.

Please use the following scale:
(0) = Does not apply to intern’s responsibilities
(1) = Excellent: Meets top expectations of criteria
(2) = Good: Consistently better than satisfactory in criteria
(3) = Average: Adequate but not more than satisfactory
(4) = Below Average: Not consistently satisfactory in criteria
(5) = Unsatisfactory: A completely unsatisfactory performance in criteria

Part I: Personal Characteristics of Intern

Attendance and Punctuality : (rating)
Lateness or absence without good reason or adequate notice.
Comments:

Personal Appearance:
In relation to his/her job, is he/she neat, clean and appropriately dressed?
Comments:

Resourcefulness:
Uses resources well; looks for new approaches and ideas.
Comments:

Judgment and Problem Anticipation:
Could he/she handle emergency situations? Does he/she make common sense decisions? Does he/she anticipate possible problem areas?
Comments:

Motivational Skills:
Is he/she enthusiastic; does he/she generate interest; can he/she get programs started?
Comments:

Acceptance of Responsibility:
Willingness to assume responsibility when situations call for it; is he/she capable of standing on his/her own decisions.
Comments:

Initiative, Creativity:
Looks for additional work, avoids idleness, originates ideas, makes creative efforts.
Comments:

Part II: Professional Relations
Public Relation Skills:
Tactful, diplomatic, courteous behavior
Comments:

Work Attitudes:
Industrious, willing to assist others, does his/her share
Comments:

Rapport with Staff:
Works harmoniously with others; cooperative, considerate, helpful
Comments:

Relates to Program Participants:
Ability to get people involved; shows interest, respect and concern for program participants.
Comments:

Adaptability:
Can adjust plans and actions according to developing situations or changing moods of group.
Comments:

Takes Criticism Constructively:
Willing to discuss and recognize weakness; works on personal problems
Comments:

Part III: Professional Proficiencies
Knowledge and Skills Performed:
Does he/she display a knowledge of program skills and techniques in development activities?
Comments:

Does he/she plan his/her activities well in advance of the program?
Comments:

Does he/she keep facilities and equipment in good condition?
Comments:

Does he/she work well with his/her participants?
Comments:

Written Communication, Reports:
Conveys ideas clearly; does neat, organized work; meets deadlines
Comments:

Oral Communication:
Expresses self well; makes points clear to public and others
Comments:

Task Accomplishment:
Tasks completed effectively and within deadlines; pursues difficult tasks to completion.
Comments:

Professional Growth:
Searches for more knowledge and experience, attends meetings, reads and discusses, inquires about profession.
Comments:

This intern: (Please check one)
_____Displays great potential
_____Displays very promising potential
_____Displays possible potential
_____Displays little potential
Please comment to support your total appraisal:

For the Mid-Term Analysis only, please suggest ways that the Intern may improve his/her performance within your agency:

Overall Performance: ________________ Pass _________________ Fail

Agency Supervisor’s Signature: __________________________________ Date: ____________

Intern’s Signature: ____________________________________________ Date: ____________

Weekly Activity Report Form H

Name: ________________________________________________________________________

Week Number: ___________From _________ to _______________ (dates)

Signature of Agency Supervisor: ___________________________________________________

Signature of Intern: ______________________________________________________________

Total Hours for the Week: ________________________________________________________

Distribution of Hours:
Conference _____________Evaluation______________Leading_________________________

Lectures________________Meetings_______________Observation______________________

Orientation ______________Participation____________Planning_________Other___________

Note: Use this page as the first page of the Weekly Activity Report; attach additional pages of report and include the following contents if appropriate:

1. A record of meetings, conferences and training sessions attended by you.
2. A record of activities, assignments and experiences encountered by you.
3. An evaluation of each scheduled activity.
4. The changes you would suggest for the Activity Report to make it more effective.
5. Any problems you incurred during the week (be sure to state the date of the problem and your action, solution, etc, to it.)
6. Any satisfying experiences which have helped you during the week.
7. Any copies of fliers, news items and other publications that you prepare or that relate to your Internship experience.

Please send into AHSU once a month!.

Student Performance Appraisal-Final Form I
To be completed as a Final Analysis one week prior to the end of the internship.
Internship Student's Name: ________________________________________________________
Agency: _______________________________________________________________________
Agency Supervisor: ______________________________________________________________

Please rate the Intern in each of the areas that follow and forward this appraisal to the AHSU/NINE Internship Coordinator.
Please use the following scale:
(0) = Does not apply to intern’s responsibilities
(1) = Excellent: Meets top expectations of criteria
(2) = Good: Consistently better than satisfactory in criteria
(3) = Average: Adequate but no more than satisfactory
(4) = Below Average: Not consistently satisfactory in criteria
(5) = Unsatisfactory: A completely unsatisfactory performance in criteria
Part I: Personal Characteristics of Intern
Attendance and Punctuality : (rating)
Lateness or absence without good reason or adequate notice.
Comments:

Personal Appearance:
In relation to his/her job, is he/she neat, clean and appropriately dressed?

Comments:

Resourcefulness:
Uses resources well; looks for new approaches and ideas.
Comments:

Judgment and Problem Anticipation:
Could he/she handle emergency situations? Does he/she make common sense decisions? Does he/she anticipate possible problem areas?
Comments:

Motivational Skills:
Is he/she enthusiastic; does he/she generate interest; can he/she get programs started?

Comments:

Acceptance of Responsibility:
Willingness to assume responsibility when situations call for it; is he/she capable of standing on his/her own decisions.
Comments:

Initiative, Creativity:
Looks for additional work, avoids idleness, originates ideas, makes creative efforts.
Comments:

Part II: Professional Relations
Public Relation Skills:
Tactful, diplomatic, courteous behavior
Comments:

Work Attitudes:
Industrious, willing to assist others, does his/her share

Comments:

Rapport with Staff:
Works harmoniously with others; cooperative, considerate, helpful
Comments:

Relates to Program Participants:
Ability to get people involved; shows interest, respect and concern for program participants.
Comments:

Adaptability:
Can adjust plans and actions according to developing situations or changing moods of group.
Comments:

Takes Criticism Constructively:
Willing to discuss and recognize weakness; works on personal problems
Comments:

Part III: Professional Proficiencies
Knowledge and Skills Performed:
Does he/she display a knowledge of program skills and techniques in development activities?
Comments:

Does he/she plan his/her activities well in advance of the program?
Comments:

Does he/she keep facilities and equipment in good condition?
Comments:

Does he/she work well with his/her participants?

Comments:

Written Communication, Reports:
Conveys ideas clearly; does neat, organized work; meets deadlines
Comments:

Oral Communication:
Expresses self well; makes points clear to public and others
Comments:

Task Accomplishment:
Tasks completed effectively and within deadlines; pursues difficult tasks to completion.
Comments:

Professional Growth:
Searches for more knowledge and experience, attends meetings, reads and discusses, inquires about profession.
Comments:

This intern: (Please check one)

___________________________Displays great potential

___________________________Displays very promising potential

___________________________Displays possible potential

__________________________Displays little potential

Please comment to support your total appraisal:

Overall Performance: ____________________ Pass_________________ Fail

Agency Supervisor’s Signature: __________________________________ Date: ____________

Intern’s Signature: ____________________________________________ Date: ____________

Created by The American Health Science University 1010 S. Joliet St., Ste 107, Aurora, CO 80012

Intern’s Summarization Report Form J

This report is to be prepared by the Intern during the final week of the internship.

Student Name: ________________________________ ID# ___________Date: _______________

Agency Name: ___________________________________________________________________

In light of your objectives, has this been a good learning experience for you? Have you been able to accomplish your objectives? What has been most valuable about this experience? What has been most disappointing?

How would you rate this position as an Intern position? Why? What recommended changes would you suggest to make it a more meaningful position? (please be as specific as possible).

Note: Staple additional pages to this if necessary

Intern Evaluation of the Internship Site                           Form K
This report is to be completed by the intern during the final week of the internship.
Intern's Name: _______________________________________________ Date: ______________
Agency Name: __________________________________________________________________
Instructions: Please rate the strengths and weaknesses of the site in terms of meeting your needs as an Intern. Use the following scale:
1– excellent          2-good           3-adequate             4-fair               5-poor
1.     Acceptance of you as a functional member of the staff; willingness to integrate you into all appropriate levels in activities, programs and projects.
2.     Provision of relevant experience in administration, supervision and leadership.
3.     Cooperation of agency staff to provide professional growth experiences through training programs, seminars, and similar activities.
4.     Provision of assistance in helping you meet your personal and professional goals and objectives.
5.    Possession of resources essential to the preparation of professionals (library, equipment, supplies, etc.).
6.     Employment of qualified, professional staff with demonstrated capability to provide competent supervision.
7.     Adequate scheduling of conferences with you and on-going evaluation of your performance.
8.     Allowance for relating classroom theory to practical situations.
9.     Willingness to listen to whatever suggestions or recommendations you might offer, and willingness to discuss them with you, explaining the rationale for their acceptance or rejection.

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