APPENDIX D
AGENCY PLACEMENT CONFIRMATION
Instructions:
This form is to be completed by the individual administratively responsible for the placement of the student
within the agency
Confirmation:
This is to certify that has been accepted as field
experience student with
(agency).
It is understood that this student is expected to work an average of _____ clock hours per week for ______
weeks.
Beginning Date
Ending Date
Exceptions:
Other:
Please provide a brief description duties and responsibilities this student will be expected to complete
The following person from our agency staff has agreed to serve as the agency supervisor for this student.
Supervisor Name (please print):
Supervisor Signature: Date
Title:
Business Street Address:
Business City, State, Zip Address:
Business Phone: ____________________________
E-mail:
Number of clock hours spent per week in this internship experience. A total of 560 hours is required over
the length of the internship. _____________________________________________________________
If the student is to be paid, or receive other types of compensation, i.e. housing, travel, indicate amount and
rate. _________________________________________________________________________________
I hereby certify that the information I am submitting is complete and accurate. I
understand that checking “I Agree” below acts as my signature on this form.
I Agree Date_____________________ (mm/dd/yyyy)
Name
_____________________________________
