University of Northern
Iowa
Department of Educational Leadership and
Postsecondary Education
EDUCATIONAL LEADERSHIP INTERNSHIP VERIFICATION
FORM
Use this form for plotting initial ideas on questions 3&4 before submitting electronically on
the
Ed Leadership Superintendency System found on MyUNIverse. (Form may
appear somewhat different on system.)
1. Name of Intern (Print):
2. Standard and proficiencies (e.g: 1.8, 2.8, 2.11, 4.3, and 4.5. See next page for list):
NOTE: Record all Standards that apply.
3. Briefly describe this internship experience, including the goal and your specific role. Make
sure to identify which type of experience you completed (course-assigned, site-determined,
ISFLC, or business):
4. Please reflect on what you have learned and how you intend to apply this learning in a
future administrative role.
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NOTE: Intern and Lead Mentor are required to have a reflective feedback and coaching conversation
at the conclusion of each internship activity.
5. Artifact developed for this experience
Yes
No
6. Intern verification: Approximate hours spent
(e.g: 1.8 = 5 hrs.)
NOTE:
Record one
Proficiency
per line and
record the
standard total
on the line
provided.
Approximate hours spent
(e.g: 2.8 = 3 hrs.)
Approximate hours spent
(e.g: 2.11 = 6 hrs.)
Approximate hours spent
(e.g: 4.3 = 4 hrs.)
Approximate hours spent
(e.g: 4.5 = 1 hrs.)
Total Hours for Activity
Student Signature
104
7. Lead Mentor verification of satisfactory completion of the above internship experience:
(Signature of Lead Mentor)
(Date)
Print Name
Standards and Proficiencies
Standard 1.4: Collective vision
Standard 1.8: Data and information
Standard 1.16: Change agent
Standard 2.7: Culture of high expectations for all leaders
Standard 2.8: Data and information
Standard 2.11: Technology
Standard 3.6: Problem/conflict resolution
Standard 3.8: Data and information
Standard 3.9: Balanced management and leadership
Standard 3.10: Finance
Standard 3.11: Technology
Standard 4.3: Ethical consideration in interactions
Standard 4.5: Communication
Standard 4.12: Diversity
Standard 4.13: Community engagement
Standard 4.15: Relationships/partnerships
Standard 5.1: Continuous reflective style
Standard 5.2: Understanding self
Standard 6.14: Broader context (multiple arenas)
Standard 6.16: Change agent
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