Internship Assignment Checklist

This checklist will be used to record when your assignments have been completed and submitted.

Assignments and evaluations should be submitted through this site. If you prefer to mail or fax your forms please send them to the Program Director of Wellness Management by the specified due dates. The current address and telephone numbers are:

Dr. Jane Ellery
Associate Director
Program Director of Wellness Management
Fisher Institute for Wellness and Gerontology
Ball State University
2000 University Avenue
Muncie, Indiana 47306
(765) 285-8259 Main Office (765) 285-8237 Fax

Items with an * indicate a required field.

Intern's Name *
Internship Supervisor's Name *

Expectation Statement Worksheet A Due 1 month Prior to Beginning Internship Experience To be completed by Intern & Site Supervisor
Date Worksheet A was completed & submitted *

Mid-term Evaluation Due end of week 7 (end of week 5 during summer) To be completed by Intern & Site Supervisor
Date Mid-term evaluation was completed and submitted *

Expectation Statement Worksheet B Due end of week 15 (end of week 10 during summer) To be completed by Intern & Site Supervisor
Date Worksheet B was completed and submitted *

Final Evaluation Due end of week 15 (end of week 10 during summer) To be completed by Intern & Site Supervisor
Date Final Evaluation was completed and submitted *

Student Internship Experience Report Due end of week 15 (end of week 10 during summer) To be completed by Intern
Date Student Internship Experience Report was completed and submitted *

Internship Site Evaluation Due end of week 15 (end of week 10 during summer) To be completed by Intern
Date Internship Site Evaluation was completed and submitted *

Monthly Reports (for part-time internships only) Due first of following month To be completed by Intern & Site Supervisor
Date Monthly Report was completed and submitted