Internship and other Experiential Education Placement Paperwork

      1.  Faculty and Student Forms
      2. Community Partner and Organization Forms

 

FORMS FOR FACULTY AND STUDENTS

Forms for individual credit-bearing Independent Internship, Practicum, or Fieldwork Placements 

      • Use this form for independent internship placements. The first page of this form will be used to register the credits, faculty will need to provide students with objectives and evaluation information for the placement.
      • Students complete the rest of the form with information about the placement.  It includes the liability waiver and personal vehicle use policy.
      • Return the form to Karen Balnis, Service Learning and Internship Coordinator.  It will be forwarded to the Registrar’s office, copies will be emailed to student and faculty member.
      • Some disciplines have their own forms, especially those involving direct client care. These are often determined by accrediting agencies and should continued to be used.

Forms for Service Learning or as part of Internship / Practicum Courses

      • Use this form for courses which include students or teams to work at a placement site as part of the course requirements. Faculty will need to provide students with objectives and evaluation information for the placement – this can be typed into the form before it is distributed to the class.
      • Students complete the rest of the form with information about the placement. It includes the liability waiver and personal vehicle use policy. (Please make sure students know if there are any hazards or risks associated with the placement.)
      • Faculty should return the completed forms to Karen Balnis, Service Learning and Internship Coordinator. Copies will be emailed to student and faculty member.

Individual forms

 


 

FORMS FOR COMMUNITY PARTNERS, ORGANIZATIONS, AND BUSINESSES

Affiliation Agreements

      • Placement sites complete Affiliation Agreements with the college.
      • To minimize duplication of efforts, when possible the following agreements will  be used for placing students from any department.  The agreements reference the Special Permissions forms (above) specific to the students/placement.  (As noted above, some programs have required discipline specific forms which take the place of these agreements.)

Department of Labor Forms

      • Unpaid internships in NH need to have both the placement site and the school complete the DOL forms.  Please contact Karen Balnis if you have any questions.
      • Placement sites must complete the pre-screening form if not already approved by NH DOL
      • School information you need for the form (unless otherwise directed for a specific program)
        • Keene State College
        • Karen Balnis
        • 603-358-2916
        • FAX 603-358-2458
      • List of pre-approved work sites
      • KSC completes the DOL form

Faculty and Student Forms
Community Partner and Organization Forms


Karen Balnis, M.Ed. RDN
Service Learning and Internship Coordinator
Academic and Career Advising
Keene State College, MS 2602
229 Main Street, Keene, NH 03435
kbalnis@keene.edu — 603-358-2916 — FAX 603-358-2458