Southeast Missouri State University

Student’s Name:
SE ID (S0#######):
Option in Major:
Total Hours Completed
Total Hours Completed
in Option Sequence

Campus Address  
Campus Phone

Cooperating Agency Information

Company Name
Company Address  
Resume on File
Phone Number
Internship/Practicum Title
for Permanent Records
Starting Date of Internship/Practicum
Closing Date of Internship/Practicum
Number of Weeks of Internship/Practicum

List of Internship/Practicum 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 as shown on Sample Logs link, totaling 180 hours worth of work
  • Two on-job work samples representing the internship/practicum (can be in draft form).
  • Supervisor’s Internship/Practicum Performance Review Form
  • Self & Program Evaluation Form

All materials and information submitted for your Internship/Practicum become property of the Department of Mass Media to be maintained in the Resource Room. 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 _________________