Student’s Name:
SE ID (S0#######):
Total Hours Completed
Total Hours Completed
in SC Courses

Campus Address

Campus Phone

Cooperating Agency Information

Company Name
Company Address  
Phone Number
Internship Title
for Permanent Records
Starting Date of Internship
Closing Date of Internship
Number of Weeks of Internship




List of Internship Work Tasks:



Additional Requirements to be fulfilled before credit is granted for internship/practicum:

  • Weekly Time Log to be submitted via email at the end of each weekly period for the total of 150 hours worth of work.
  • Two on-job work samples representing the internship (can be in draft form).
  • Supervisor’s Internship Performance Review Form.
  • Self & Program Evaluation Form.

All materials and information submitted for your Internship/Practicum become property of the Department of Communication Studies to be maintained in the main department office. These items cannot be returned.

Student’s Signature ____________________________________________ Date _________________________
Company Representative’s Signature ____________________________________________ Date _________________________
Internship/Practicum Coordinator's Signature ____________________________________________ Date _________________________
Department Chair’s Signature ____________________________________________ Date _________________________