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 *