KUTZTOWN UNIVERSITY DEPARTMENT OF COUNSELING AND
HUMAN SERVICES
M.ED. STUDENT AFFAIRS IN HIGHER EDUCATION ADMINISTRATION
PRACTICUM SITE AGREEMENT
* Students will complete this form, and the on-site supervisor will sign indicating that she/he
agrees to the practicum requirements.
Student Information:
Name: ________________________________________________________________
Home Address:_________________________________________________________
Home Phone:_______________________ Cell Phone:_________________________
Ku Student ID #:______________ KU Email Address:__________________________
Semester:
Fall
Spring Summer
Circle
Year:_______
Practicum Site Information:
College/University Name:______________________________________________
Department or Functional Area:__________________________________________
Phone Number__________________________________ Ext._________________
Address:_____________________________________________________________
____________________________________________________________________
Student Intern Days On-Site:_____________________________________________
On-Site Supervisor Information:__________________________________________
(Print Name)
Email Address:_______________________ Phone:__________________________
Degree & Field of Study:________________________________________________
Years of Experience:________________ Years at Current Institution:____________
Please review all practicum requirements and sign on page three of this document. All pages of
the site agreement should be turned in to your Kutztown University Practicum Supervisor by the
first Friday in December.
KUTZTOWN UNIVERSITY DEPARTMENT OF COUNSELING AND
HUMAN SERVICES
M.ED. STUDENT AFFAIRS IN HIGHER EDUCATION ADMINISTRATION
PRACTICUM SITE AGREEMENT
In accordance with the standards and guidelines established for Masters Level Student Affairs
Professional Preparation Programs by the Council for the Advancement of Standards in Higher Education
(CAS), the practicum should 1.) provide students exposure to both the breadth and depth of student affairs
work, and 2.) provide students experience in developmental work with individual and groups of students
in: program planning, implementation, or evaluation; staff training, advising, or supervision; and
administrative functions and processes as appropriate to the activities and duties of a specific functional
area. The practicum is conducted under the supervision of a student affairs professional holding at
minimum a Masters degree in Student Affairs, College Student Personnel, Higher Education, or a related
field with several years (minimum 3 to 5) of successful professional experience, including several years at
the current institution.
I. The On-site Supervisor shall be responsible to:
 Assist with the development of the goals and objectives for the practicum.
 Ensure that the student has the opportunity to engage in the full range of both direct and indirect
service to diverse student populations as appropriate to the functional area, and as specified on the
course syllabus.
 Provide the student with a minimum of one (1) hour per week of direct supervision.
 Signing off on all projects and/or records related to the student’s work, including work with
individual and/or groups of students as appropriate to the functional area. This signifies that you
have reviewed the materials (student notes, permission papers, etc.).
 Maintain contact with the faculty supervisor regarding concerns and/or for feedback regarding the
progression of the practicum. This includes meeting with the faculty supervisor once during the
practicum semester.
 Complete a formal evaluation of the student’s performance at the end of the experience utilizing
the evaluation protocol provided.
II. The University shall be responsible to:
 Designate a faculty supervisor who will coordinate the practicum.
 Assist the student in designing the goals and objectives of the practicum.
 Conduct an on-site visitation.
 Provide the student weekly supervision.

Solicit evaluative input from the on-site supervisor and assume primary responsibility for
assigning a grade.
KUTZTOWN UNIVERSITY DEPARTMENT OF COUNSELING AND
HUMAN SERVICES
M.ED. STUDENT AFFAIRS IN HIGHER EDUCATION ADMINISTRATION
PRACTICUM SITE AGREEMENT
III. The Practicum Student shall be responsible to:
 Provide proof of student affairs liability insurance (purchased through ACPA or NASPA).
 Review site agreement form and hour requirements with site supervisor.
 Engage in the full range of both direct and indirect service to a diverse array of student
populations as appropriate to the functional area.
 Successfully complete a minimum of 100 clock hours per three (3) credit hours of practicum
credits.
 Maintain an accurate, written daily log of activities and experiences, and secure site supervisor’s
signature on a weekly basis.
 Fulfill all course requirements as assigned by the faculty supervisor.
 Perform all duties and activities in accordance with FERPA, ACPA, NASPA, and CAS Ethical
Standards, policies of the on-site agency, Kutztown University, and PA Law.
IV. Problems and Termination of Agreement
 The term of this Agreement shall be 1 academic semester.
 If problems/concerns arise with the Practicum Student or terms of the site agreement, the faculty
or on-site supervisor may make modifications or terminate the agreement ONLY in consultation
with all parties involved. Follow these steps for modification or termination of agreement.
1. Contact the University Supervisor or Site Supervisor within 48 hours to discuss
termination.
2. Notify the practicum student within 48 hours of the concern.
3. Submit a written report of concerns to all parties involved.
4. Make a decision for modification or termination of agreement in consultation with all
parties.
5. If applicable, issue an amendment to the agreement.
 Upon consultation, any party may terminate this Agreement.
 Nondiscrimination. The parties agree to continue their respective policies of nondiscrimination
based on Title VI of the Civil Rights Act of 1964 in regard to sex, age, race, color, creed, national
origin, Title IX of the Educational Amendments of 1972 and other applicable laws, as well as the
provisions of the Americans with Disabilities Act.
The undersigned agree to all the provisions stated in the Practicum Site Agreement (students are only
responsible for obtaining the On-site supervisor’s signature and providing their own):
Practicum Student_______________________________________ Date____________________
On-Site Supervisor______________________________________
Date____________________
University Supervisor____________________________________ Date_____________________