Please use this form to record the number of community service-learning hours per week. This report should be initialed weekly by your agency supervisor.
At the end of your commitment, the placement site supervisor verifies total hours and completes the Student Evaluation. See bottom of form for distribution.
Final Student Evaluation (Organization/Placement Site completes)
Student Name: Student B#: College Instructor:
Community Partner Name:
Partner Email:
Community Partner Supervisor Name:
Type of Activity: ❏ Human Service Experience (1 credit) ❏ Community Involvement (3 credits) ❏ Field Study (1 credit) ❏ Volunteer
❏ Service-Learning Option ❏ Student Organization/Club (Service Activity) ❏ Internship
Total Supervisor’s Total Supervisor’s
Date M T W R F S S # Hours Initials Date M T W R F S S # Hours Initials
overall needs cannot overall needs cannot
performance help average good excellent rate performance help average good excellent rate
Attendance: Initiative:
Dependability: Attitude:
Responsibility: Cooperative:
Overall Evaluation of Performance and Comments:
VERIFICATION: I certify that the above information and following total completed hours are correct: TOTAL HOURS
CENTER FOR SERVICE-LEARNING AND CIVIC ENGAGEMENT
HOUR REPORT/SHOAT VERIFICATION AND FINAL EVALUATION
Cocoa 321-433-7610 • Titusville 321-433-5016 • Melbourne 321-433-5610 • Palm Bay 321-433-5253
CS-004 Rev. 6-13 3pt NCR DISTRIBUTION: White (Service Learning Instructor) Yellow (Center for Service Learning and Civic Engagement) Pink (Student)
Official Use Only:
Date Received:
Verbal Verification Date: Input by:
Community Partner Supervisor’s Signature Date Student’s Signature Date
and Civic Engagement
-
1/12/2015 3.5 2.25 5.75
