NIU Internship Outcome Questionnaire – Pre-Application Section
Name: ______________________ Internship Cycle (e.g., 2010-2011): _____________
_________________________________________ Number of Years in the Program:
Dissertation:
Date Dissertation Proposal Approved: __________________
Did you start collecting data for your dissertation prior to application deadlines? YES NO
Do you expect to defend your dissertation prior to leaving for internship? YES NO
If not, are you planning to defend your dissertation during the internship year? YES
Did you defend your dissertation prior to the application deadline? YES
NO
NO
Academic Accomplishments:
Total Number of Publications in Peer Reviewed Journals Prior to Application Deadlines: ____________
Number of First Author Publications in Peer Reviewed Journals:
Total Number of Conference Presentations Prior to Application Deadlines:
____________
____________
Number of First Author Conference Presentations:
Number of Presentations at Regional Conferences (e.g., MPA, WPA)
Number of Presentations at Nationally/Internationally Recognized Conferences
____________
____________
____________
(e.g. APA, APS, ICIS, SRCD, etc.)
Overall GPA:
How many PSYCH 102 Sections have you taught?
____________
Number of Semesters in Program Before Completion of Master’s Thesis:
Did you publish your Master’s Thesis?
How Many Semesters of Teaching Experience prior to the application deadline?
(Include Semester of Application Deadline if Applicable)
YES
____________
NO
____________
____________
How many upper-level courses have you taught? ____________
Upper Level Title: ____________________________________________________________________
Upper Level Title: ____________________________________________________________________

Clinical Experience: Please submit the Time2Track AAPI Summary Report or complete the following:
Total Number of Practicum Hours Counted on the APPIC Application: ____________
____________ Total Number of Collateral Hours (i.e., all hours not face-to-face or in supervision):
Total Number of Client Contact Hours:
Assessment
Therapy
____________
____________
Consultation
Total Number of Child/Adolescent Contact Hours:
Assessment
____________
____________
____________ Therapy
Consultation
Total Number of Individual Supervision Hours:
Total Number of Group Supervision Hours:
Number of different clinical assessment techniques you have learned to administer. Do not count questionnaires (e.g., CBCL, BASC, BDI-II) or structured/semi-structured interviews (e.g., SCID). You should include measures such as the WISC-IV, WAIS-IV,
WIPPSI-III, Bayley-II, and/ or neuropsychological measures (e.g., memory, executive functions, Language, etc.).
Total Number of Integrated Assessments:
____________
____________
____________
____________
____________
Total Number of Adult Integrated Assessments:
Total Number of Child/Adolescent Integrated Assessments:
Number of School Based Consultations (e.g., PPT/IEP meeting where you presented assessment findings):
____________
____________
____________
Number of adult treatment cases seen: ____________
Number of long-term (i.e., at least three consecutive semesters) adult clients/patients: ____________
Number of child/adolescent treatment cases seen: ____________
Number of long-term (i.e., at least three consecutive semesters) child/adolescent treatment cases seen: ____________

Everyone should complete the following:
Number of different practicum sites:
List each site and number of all hours at each site:
____________
Site 1: ________________________________________________________ Hours: ____________
Site 2: ________________________________________________________ Hours: ____________
Site 3: ________________________________________________________ Hours: ____________
Site 4: ________________________________________________________ Hours: ____________
Site 5: ________________________________________________________ Hours: ____________
Site 6: ________________________________________________________ Hours: ____________
Career Goals (i.e. Type of Position you plan on seeking after internship and/or postdoctoral training).
Do you plan to pursue postdoctoral training after internship in a (Circle One):
Clinically Oriented Site Research Oriented Site Combination Research/Clinical Site
Other: ___________________________ Not Planning to Seek Postdoctoral Training
What type of position do you anticipate seeking after your training is completed (i.e. after internship if not planning to seek postdoctoral training or after postdoctoral training) Circle One:
Academic Job (Research + Teaching) Academic Job (Teaching)
Academic Job (Clinical + Research) Clinical Position (Private/Group Practice)
Clinical Position (e.g., Medical Center/Community Mental Health/University Counseling Center)
Clinical + Some Teaching (e.g., Private Practice and Teaching at Community College)
School Based Setting
Military (i.e. will enlist)
Industry
Other (Describe/Identify): ___________

7.
9.
3.
5.
Rank Order Types of Settings to which you anticipate applying (1 should be what you circled above; Do not Rank any career setting to which you would NOT apply under any circumstances):
1. ____________________________ 2. ___________________________
____________________________
____________________________
4.
6.
___________________________
___________________________
____________________________
____________________________
8.
10.
___________________________
___________________________
On a scale from 1 (Completely Uncertain) to 7 (Completely Certain, Nothing can Change your mind), rate your level of certainty regarding your post-internship and/or post-doctoral career goals:
1 2 3 4 5 6 7
Internship Application Related Information:
Total Number of Internship Sites to which You Submitted Applications:
Total Number of different states represented by sites to which you applied:
____________
____________
Number of sites within the state of Illinois to which you submitted applications: ____________
Hypothetically, assume you receive interviews at all the sites to which you have applied and also assume that each site will rank you competitively. Knowing no other information than what is available to you now (i.e. before the actual interview invitations), list in order of preference your top five choices:
1.
______________________________________________________________________________
2.
______________________________________________________________________________
5.
3.
______________________________________________________________________________
4.
______________________________________________________________________________
______________________________________________________________________________

List the two sites that are choices of “last resort” or “safe” sites:
____________________________________________________________________________________
____________________________________________________________________________________
Rank in order the importance of the following factors you considered in your rankings:
Research Opportunities: ________________ Clinical Training Opportunities:_______________
Potential for Postdoc at same site: _____________ Reputation: __________________________
Location: _________________________________ Fit with Career Goals: _________________
Fit with prior experiences: ___________________
Recommendation by Prior Student or faculty: ______________________
Other (Describe): _____________________________________________________________________

NIU Internship Outcome Questionnaire – Post-Application/Interview Section
Name: ______________________ Internship Cycle (e.g., 2010-2011): _____________
Number of interviews: ____________
List all sites where you received interviews in order of final rankings that you submitted; if you did not rank a site, list it last and indicate NOT RANKED:
1.
______________________________________________________________________________
2.
______________________________________________________________________________
3.
______________________________________________________________________________
4.
______________________________________________________________________________
5.
______________________________________________________________________________
6.
______________________________________________________________________________
7.
______________________________________________________________________________
8.
______________________________________________________________________________
9.
______________________________________________________________________________
10.
______________________________________________________________________________
11.
______________________________________________________________________________
12.
______________________________________________________________________________
13.
______________________________________________________________________________
14.
______________________________________________________________________________
15.
______________________________________________________________________________

NIU Internship Outcome Questionnaire – Post-Match Day
Name: ______________________ Internship Cycle (e.g., 2009-2010): _____________
Did you “match?” YES NO
If YES –
Where did you Match: _________________________________________________________________
On a scale from 1 (Very Unsatisfied) to 7 (Very Satisfied), rate your satisfaction with the outcome of the match process:
5 6 7 1 2 3 4
If you did not match, did you go through MATCH 2? YES NO
If Yes, did you obtain a placement? YES NO