On-site Supervisor
Intervention Plan
NOTE: The University Supervisor is notified as early as possible concerning any prospective "D" or
"F" intern. A conference is scheduled with the intern, on-site supervisor, and university supervisor to
develop an intervention plan. The plan outlines the requirements that must be met by the intern in order
to improve performance and earn a grade of C or above (or an alternate plan for changing to a nonlicensure track). The intern, on-site supervisor, and university supervisor must sign the plan.
Intern:
University supervisor:
On-site supervisor:
Date:
Describe the nature of the concern:
Summarize the discussion:
State the action(s) to be taken:
Person(s) responsible:
Date for evaluation:
Intern’s signature:
University supervisor's signature:
On-site supervisor’s signature:
Program Director signature: