Fill - Free fillable Directions for Completion of Internship Form For Deans (Clarion University of Pennsylvania) PDF form

Directions for Completion of Internship Form

For

Dean’s Office

THE DIRECTIONS MUST BE COMPLETED BEFORE THE STUDENT

BEGINS THE INTERNSHIP.

1. Enclosed you will find the original standard university affiliation agreement for

your signature. After all signatures are affixed, one original will be returned to you

and the agreement will be deemed effective.

• Sig

natures. It is important that any individual who signs on behalf of your

institution has contracting authority to legally execute the enclosed

agreement.

2. Thi

s internship agreement is to be completed by the faculty member teaching the

course that includes the internship in cooperation with the student who is doing the

internship.

3. The

student is responsible for obtaining all required signatures as listed on the

agreement.

4. Onc

e the agreement is completed with all signatures, the student brings the

agreement to the Dean’s Office.

5. The

original agreement will be forwarded by the Dean’s Office to the Registrar

for processing. A copy will be kept in the Dean’s Office for no more than one

academic year after the end of the internship.

6. The student will:

• keep one copy of the agreement.

• give one copy of the agreement to the course instructor.

___________________________________________________________________________________________

LEARNING AGREEMENT FOR COOPERATIVE EDUCATION INTERNSHIP PROGRAM

Page 1 of 4

Revised 2/2020

CLARION UNIVERSITY OF PENNSYLVANIA

LEAR

NING AGREEMENT

COOPERATIVE EDUCATION INTERNSHIP PROGRAM

LLEGE OF

________________________________________________________________________

DEPARTMENT OF ____________________________________________________________________

The Student is to submit the completed Learning Agreement to the Dean's Office before the start of the semester for the

Cooperative Education Internship Program. This form will be returned to the student before the indicated "end date" for

performance evaluation.

Term: (indicate year and mark term/session) Year: 20______ Fall _____ Spring _____

Summer 1 _____ Summer 2 _____ Summer 3 _____ Summer/7 week 1 _____ Summer/7 week 2 _____

Course & Number: _________________ Course Title: ______________________________________________

No. of Credit Hours: _______ Total Work/Clock Hours: _______ Placed in program as: __________________

Start Date: ___________ End Date: ____________ Previous Cooperative Education Intern Credits Earned: _____

Vol

untary: ______ Paid: ______ Exchange for Room/Board/Other: _________

Student Name: ___________________________________________ Clarion ID: _______________________

Current Address: ___________________________________________________________________________

Telephone Number: _______________________ Credits Completed: _______________ GPA: ____________

Student Major or Career Goal: _________________________________________________________________

1. STATEMENT OF JOB-OR

IENTED/LEARNING OBJECTIVES (To be completed prior to start of

Cooperative Education Internship Program as Part A of this agreement.)

2. EVALUATION OF STUDENT PERFORMANCE (To be completed and submitted at end of Cooperative

Education Internship Program as Part B of this agreement.)

RATIFICATION: We, the undersigned, accept the validity of the job-oriented/learning objectives and evaluation

of student performance criteria in this Agreement. This Learning Agreement is governed by the terms and

conditions set forth in the University's Worksite Affiliation Agreement (Attachment A).

____________________________________________________

STUDENT SIGNATURE/DATE

____________________________________________________

WORKSITE SUPERVISOR SIGNATURE/DATE

____________________________________________________

ACADEMIC ADVISOR SIGNATURE/DATE

____________________________________________________

WORKSITE SUPERVISOR NAME, TITLE

____________________________________________________

FACULTY COORDINATOR PRINT & SIGN/DATE

____________________________________________________

WORKSITE NAME & TELEPHONE NUMBER

____________________________________________________

DEPARTMENT CHAIR SIGNATURE/DATE

1.___________________________________________________

WORKSITE ADDRESS CITY STATE ZIP CODE

____________________________________________________

DEAN SIGNATURE/DATE

2.___________________________________________________

WORKSITE ADDRESS CITY STATE ZIP CODE

Forward the completed Learning Agreement to the Dean’s Office who will then forward it to the Registrar for

Processing.

_____________________________________________________________________________________

LEARNING AGREEMENT FOR COOPERATIVE EDUCATION INTERNSHIP PROGRAM

Page 2 of 4

Revised 2/2020

PART

STATEMENT OF JOB-ORIENTED/LEARNING OBJECTIVES

(To be completed prior to start of Cooperative Education Internship Program)

PART B

EVALUATION OF STUDENT PERFORMANCE

(To be completed and submitted at end of Cooperative Education Internship Program)

___________________________________________________________________________________________

LEARNING AGREEMENT FOR COOPERATIVE EDUCATION INTERNSHIP PROGRAM

Page 3 of 4

Revised 02/2020

For Department Use Only

Worksite Type Code & Description:

AGR - Agriculture and Natural Resources

ART - Arts, Entertainment and Media

BUS - Business, Construction and Manufacturing

EDU - Education

GOV - Government, Law and Public Administration

HLT - Healthcare

LIB - Library (non-Educational setting)

MIL - Military

NPT - Non-profit or Not-for-Profit

Employer Name: ____________________________________________________

Employer Address: __________________________________________________

Street or PO

______________________________________________________

City State Zip Code

Employer Contact Name: _____________________________________________

Employer Phone: ___________________________________________________

Employer Email: ____________________________________________________

Party Contractor Name: ___________________________________________

Party Contractor Address: __________________________________________

Street or PO

______________________________________________________

City State Zip Code

Party Contractor Contact Name: _____________________________________

Party Contractor Phone: ____________________________________________

Party Contractor Email: _____________________________________________

_____________________________________________________________________________________________

LEARNING AGREEMENT FOR COOPERATIVE EDUCATION INTERNSHIP PROGRAM

Page 4 of 4

Revised 02/2020

ATTACHMENT A

ARION UNIVERSITY OF PENNSYLVANIA

AFFILIATION AGREEMENT WITH A WORKSITE PROVIDER

IS AGREEMENT, is made by and between CLARION UNIVERSITY OF PENNSYLVANIA,

(hereinafter referred to as “University”), an educational institution of the State System of Higher

Education, Commonwealth of Pennsylvania and the Worksite Provider (hereinafter “Worksite”). The

parties intend to be legally bound to the following terms:

I. DUTIES AND RESPONSIBILITIES OF THE UNIVERSITY

a. Se

lection of Students. The University shall be responsible for the selection of qualified students t

rticipate in the worksite experience. Selected students must have the appropriate educational

background and skills consistent with the contemplated educational experience offered by the

worksite and must be approved by the designated representative of the Worksite

b. E

ducation of Students. The University shall assume full responsibility for the classroom education

of its students. The University shall be responsible for the administration of the program, the

curriculum content, and grading

c. Submission of Candidates. The University shall submit the names of the students to the Worksite

or a designated representative prior to the worksite assignment

d. A

dvising Students of Rights and Responsibilities. The University will be responsible for advising

the student of his or her own responsibilities under this Agreement. The student shall be advised of

his or her obligations to abide by the policies and procedures of the Worksite and should any student

fail to abide by any policy and/or procedure, he or she may be expelle

e. P

rofessional Liability Insurance. When students are placed at a worksite where employees are

normally expected to provide their own professional liability insurance, then these students shall be

responsible for procuring professional liability insurance at their own expense. The limits of the

policy shall be a minimum of $1,000,000.00 per claim and an aggregate of $3,000,000.00 pe

currence. This policy must remain in full force and effect for the duration of the worksite

assignment

II. DUTIES AND RESPONSIBILITIES OF THE WORKSITE PARTNER

a. Establishment of worksite experience. The Worksite authorizes the use of its facilities as may be

greed upon by the Worksite and the University as a work experience center. This work experience is

for students enrolled in one of the University’s programs.

licies of the Worksite Provider. The University and the Worksite will review with each student,

prior to the assignment any and all applicable policies, codes or confidentiality issues related to the

experience. The Worksite will provide the University all the applicable information prior to the

Student’s participati

on.

_____________________________________________________________________________________________

ATTACHMENT A

ACADEMIC AFFILIATION AGREEMENT

Page 1 of 3

Revised 11/2017

c. Administration. The Worksite will be responsible for and retain control over the organization, and

ope

ration of its programs. The University will assign a faculty member to serve as University Faculty

Coordinator during the course of the student’s internshi

Removal of Noncompliant Student. The Worksite shall have the authority to immediately remove a

student who fails to comply with its policies and procedures. If such a removal occurs, the Worksite

should immediately contact the responsible University Faculty Coordinat

or.

Designation of Representative. The Worksite shall designate a person to serve as a liaison between

the parties who will meet periodically (either in person, over the phone, or electronically) with the

Faculty Coordinator in order to discuss, plan and evaluate the experience of the student(s).

f. Supe

rvision of Students. The Worksite shall provide a Worksite Supervisor who will supervise

student activities during the work experience

g. Reporting of Student Progress. The Worksite shall provide all reasonable information requested by

the University on a student’s work performance. If there are any student evaluations, they will be

completed and returned according to any reasonable schedule agreed to by the University and the

Worksite

h. Student Records. The Worksite shall protect the confidentiality of student records as dictated by

the Family Educational Rights and Privacy Act (FERPA) and shall release no information absent

written consent of the student unless required to do so by law or as dictated by the terms of this

Agreement

III. MUTUAL TERMS AND CONDITIONS

Number of Participating Students. The parties will mutually agree upon the number of students

that shall be assigned to the Worksite for work experiences

Term of Agreement. The term of this Agreement shall be for the period specified in the Learning

Agreement. This Agreement may not exceed a period of five years.

c. T

ermination of Agreement. The University or the Worksite may terminate this Agreement for any

reason with ninety (90) days’ notice. Either party may terminate this Agreement in the event of a

substantial breach. However, should the Worksite terminate this Agreement prior to the completi

of an academic semester, all students enrolled at that time may continue their educational experience

unt

il it would have been concluded absent the termination.

d. Int

erpretation of the Agreement. The laws of the Commonwealth of Pennsylvania shall govern this

Agreement.

e. Modi

fication of Agreement. This Agreement shall only be modified in writing with the same

formality as the original Agreement.

Relationship of Parties. The relationship between the parties to this Agreement to each other is that

of independent contractors. The relationship of the parties to this contract to each other shall not be

construed to constitute a partnership, joint venture or any other relationship, other than that of

independent contractors

__________________

_______________________________________________________________

ATTACHMENT A

ACADEMIC AFFILIATION AGREEMENT

Page 2 of 3

Revised 11/2017

g. Nondiscrimination. The parties agree to continue their respective policies of nondiscrimination

based on Title VI of the Civil Rights Act of 1964 in regard to sex, age, race, color, creed, national

origin, Title IX of the Education Amendments of 1972 and other applicable laws, as well as the

provisions of the Americans with Disabilities Act. UNIVERSITY students are protected by Title IX

of the Education Amendments of 1972 and other applicable laws, as well as the provisions of Section

504 of the Rehabilitation Act of 1973 (as amended) and the Americans with Disabilities Act (ADA)

of 1990. CLINIC agrees to cooperate with the UNIVERSITY in its investigation of claims of

discrimination or harassment.

h. Reporting of Sexual Violence and Sexual Harassment. Clinic shall report any incident in which a

student is the victim of sexual assault, dating violence, domestic violence, stalking or sexual

harassment to the University Title IX Coordinator:

Dr. Susanne Fenske

Vice President of Student Affairs

840 Wood Street

Clarion, PA 16214

814-393-2351

i. L

iability. Neither of the parties shall assume any liabilities to each other, except as specifically

stated in this Agreement. As to liability for damage, injuries or death to persons, or damages to

property, the parties do not waive any defense as a result of entering into this Agreement unless such

a waiver is expressly and clearly written into a part of this Agreement.

j. Entire Agreement. This Agreement represents the entire understanding between the parties. No

other prior or contemporaneous oral or written understandings or promises exist in regards to this

relationship.

______________________________________

Clarion University of Pennsylvania

__________________________________

Site Name

______________________________________

Provost - Print Name/Title

__________________________________

Print Name/Title

Provost’s Signature

__________________________________

Authorized Signature

_________________________________________________________________________________

ATTACHMENT A

ACADEMIC AFFILIATION AGREEMENT

Page 3 of 3

Revised 11/2017

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