REQUEST FOR ADDITIONAL PRACTICUM SITE APPROVAL HOURS TO EXCEED 20
HOUR PER WEEK WORK LOAD ASSIGNMENT
Please fill out the information below. Submit this form to your division director. He or she will present your
request to your program facalty for review.
Student Name
Current GPA:
OR
Qualifying Exam: Date completed
Date of Dissertation proposal
Program
Date to be taken
Date of dissertation
Number of hours per week currently working at an RA or TA
Please list all practicum sites that you are currently enrolled in: Give the name, number of hours worked per week,
whether the placement is paid or unpaid
NAME OF SITE
HOURS
PAID/UNPAID?
Unpaid
Unpaid
Unpaid
NAME OF SITE YOU WISH TO ADD:
Number of paid hours per week:
Semester(s)
Time period requested
Name of Supervisor
In the space below, please indicate your reasons for wanting to add this practicum placement. It is important
that we know you justification for exceeding the 20 hour per week work load set by the department. Each
request will be evaluated on a case by case basis.
Signature of Advisor: Your signature below indicates support of this student’s request.
Date
Signature
APPROVED
DCT Signature
NOT APPROVED
Date