Student Intern Internship Site Evaluation

Wellness - Student Intern Internship Site Evaluation

The purpose of this from is to collect subjective information from the intern regarding the internship experience.

The site evaluation is completed by the Intern at the end of the internship experience and is submitted to the Program Director of Wellness Management. The purpose of this form is to collect subjective information from the intern regarding the internship experience. The information provided is filed in the Resource Center for confidential and proprietary use by future wellness management students considering the Internship site.

Items with an * indicate a required field.

Intern's Name *
Term Internship Completed *
Date of this report *
Internship Site *
Internship Supervisor's Name *
Title *
Address *
City *
State *
Zip *
Country
Phone *
Fax *
E-mail address *
Would you recommend this internship site to future wellness interns? *

Type of Work Environment and Facilities
Check all that apply *	Corporate/Office Manufacturing Skilled Labor Military Government University Health Care/Hospital Senior Citizens Center Entertainment/Restaurant Recreation/Fitness Facility Faculty/Staff/Students Children Older Adults Service Workers Blue-collar Not-for-profit Unionized Work Force Human Resources Community Resources White-collar Other
If you checked 'other' please describe the additional Work Environment and Facility

Types of Wellness/Health Promotion Services and Programs
Check all that apply *	Fitness Facility Weight Management Comp Time Flex Time Health Screenings Walking Program Newsletter Tuition Reimbursement Child Day Care Self-Care Education Ergonomics Health & Safety Recycling Financial Planning Retirement Planning Stress Management EAP Aerobics Other
If you checked 'other' please describe the additional Wellness/Health Promotion Services and Programs

Compensation
Check all that apply *	Meals Housing No compensation Stipend Other
If you checked 'stipend' please include the amount and whether it is per hour or per week etc.
If you checked 'other' please describe the alternative form of compensation

Intern Certification Requirements
Check all that apply *	CPR First Aid Proof of Liability Insurance Other
If you checked 'other' please describe additional Intern Certification Requirements

Application Requirements
Check all that apply *	Letter of Application Resume Transcripts References Other
If you checked 'references' please list the number required
If you checked 'other' please describe additional application requirements

Description of Internship Experience
Please list the skills you were able to develop during your internship experience *

List the major duties you were assigned *

List the strengths of the internship site and experiences *

List ways the internship experience could be improved *

List the skills which may have better perpared you for the internship experience *

Additional Comments *