Revised October 2017
Tenth Day Internship Report
Ohio State ATI
Student Information
Student Name:
Academic Program:
Home Address:
City:
State:
Zip:
Home Phone:
Internship Phone:
Best Time To Call:
Student’s Internship Address:
City:
State:
Zip:
e-mail:
Employer Information
Employer:
Employer’s Address:
City:
State:
Zip:
Intern Supervisor:
Title:
Employer’s Fax:
e-mail:
Employer’s Phone:
Best Time To Call:
Have you discussed this internship with your supervisor?
With anyone else?
If so, whom?
Does your employer/supervisor seem satisfied with this internship?
Are you satisfied with this internship?
Are all relations with your employer and fellow employees satisfactory to date?
Work Experience
On a separate sheet, list your work experiences to date and provide examples of how you are relating the principles taught in
the classroom to your experiences.
Internship Location
Provide a map and/or directions as per your instructor’s specific instructions.
Please make copies of this completed form for your records and your supervisor.
The original is to be sent to the internship instructor.