Internship Activity Report (To Be Completed by the Student)
Ohio State ATI
Report # ______
Student Information
Student Name:
Academic Program:
Supervisor:
Phone:
e-mail:
Reporting Period from to
Activity Record
Approximate
Hours
Skills Learned/Used
Proficiency Level
(good, average, poor)
Total Hours Worked: _________
Absences
Time Absent from Duty: Days Hours
Reason for Absence(s):
Signatures
Submitted by Intern:
Date:
Verified by Supervisor:
Date:
Please make copies of this completed form for your records and your supervisor.
The original is to be sent to the internship instructor.