Project Course Application – EXL/IPL 301
For IPL Office Use
1. The student should complete this form AFTER identifying his/her
project. (The same process applies for online students.)
2. Once completed, the student should have the field supervisor (supervisor
of the project work) sign on page 4.
3. Once the field supervisor has signed, the student should obtain
department approval with a signature on page 4.
4. Submit the completed form to IPL in Brookens 482 or ipl@uis.edu; upon
approval, the student will receive an email regarding course approval to
register for the Project course, EXL/IPL 301.
Project Semester/Year:
DATE RECEIVED:
COURSE:
CRN:
UIS SUPERVISOR:
APPROVAL:
☐ Spring 20____ ☐ Summer 20____ ☐ Fall 20____
STUDENT INFORMATION
Student Name:
University ID Number:
Phone:
UIS Email Address:
Academic Program/Major:
____
Academic Advisor:
Expected Graduation Date: ___________________ ☐Are you an international student?
☐ Are you receiving military benefits?
PROJECT FOCUS INFORMATION
Field Supervisor's Name:
Phone:
___
__
Title:
E-Mail: __
___
___
Field Supervisor’s Affiliation (Department/Organization/Company): ____________________________________________________
Address: _______________________________ City: ___________________ State: ____ Zip Code: _______ Country: __________
Is this Project
☐ PAID
☐ UNPAID?
Fifty (50) hours of work must be completed for each credit.
Total semester credit hours: ________
x
50 = _________ Total number of hours to be worked
All projects must be at least eight (8) weeks in length. Fifteen (15) weeks is average for fall and spring semesters.
Beginning Date: ________________
Ending Date: ________________
Proposed number of weeks: ________
Average number of hours per week: ________
How will you use this credit (consult with your advisor if needed)?
ECCE Engagement or ECCE Elective?
Number of Credits ______
General Electives?
Number of Credits ______
University Requirement (pre-2007 catalog)?
Number of Credits ______
University of Illinois Springfield
Internships and Prior Learning Services IPL
One University Plaza MS BRK 482 • Springfield, IL 62703-5407
217-206-6640 • Fax: 217-206-7415
ipl@uis.edu • www.uis.edu/ipl/
Attach a separate sheet of paper that provides a detailed project proposal. Address each of the questions below.
1.
Describe the proposed project. Describe the end product. Will it be patented/published? Include the process in your plans.

If applicable, discuss the prototype for possible publication.
2.
Provide a timetable of the tentative stages of development & completion.
3.
Briefly discuss how the project will proceed, including the perceived roles of Field Supervisor and UIS Supervisor. Include
how often and how you will meet with the Field Supervisor. You must meet with your Field Supervisor at least once each
week during the semester either in person/telephone/video conference to receive assistance, next step guidance, or
encouragement; answer and ask questions and maintain quality control.
4.
Is this Project being done at your current employment?
☐ Yes
☐ No

If yes, define how this project significantly differs from your previous/regular duties.

How many hours each week will be devoted to the new experiences?
5.
What do you want to accomplish and learn from this experience? Briefly, list at least 5 or 6 objectives. These are
tentative objectives. Consider that you might explore or confirm a career choice, develop a better understanding of the value
of diversity, identify social issues, develop and apply leadership skills, engage with the community where you are
living/visiting, apply academic and disciplinary knowledge.
6.
List the academic coursework, experiences, and/or skills you have that will be an asset in your proposed Project.
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STUDENT SIGNATURE
As a currently enrolled UIS student and by signing this contract, I understand (PLEASE INITIAL EACH STATEMENT):
In order to earn academic credit I must:
______ Participate in the seminar classes (online or on-ground) held during the semester.
______ Stay up to date on assignments and project work based on due dates I set at the beginning of the semester.
______ Keep a reflective journal of every day I work on the project. Hours not recorded in the journal do not count towards my total.
______ Create a learning contract that includes learning objectives, the activities/experiences that will be done to achieve them, and
the methods for evaluating achievement.
______ Schedule and participate in a site visit with the Field Supervisor and UIS Supervisor.
______ Contact my course instructor immediately if I start to fall behind or have questions.
______ If completing a project for more than 6 credit hours, I must complete additional course requirements.
If I am working with an external organization, as an ethical representative of UIS, I will:
______ Dress appropriately for the work place as defined by the employer’s dress code.
______ Demonstrate respect, dependability and cooperation with my supervisor and co-workers.
______ Ask questions to identify/clarify any confusion regarding my project responsibilities.
______ Maintain a strictly professional relationship with my supervisor and co-workers.
______ Refrain from the consumption of alcohol and/or drugs while completing my project.
______ Adhere to organizational policies, including confidentiality of personnel, projects, and research.
______ Strive to understand what constitutes a permissible work absence and who to notify if absent.
______ Report changes in schedule, supervision, or problems to my UIS supervisor.
______ RELEASE: In consideration of being permitted to participate in the above-noted placement as an Project (AST), in full
recognition and appreciation of the dangers inherent in participation in said placement and related activities, do hereby agree
to assume all risks and responsibilities surrounding participation in the above-noted placement and activities undertaken as an
adjunct thereto; and further, I do for myself, my legal representatives, my heirs and assigns, agree to defend, hold harmless and
indemnify, and hereby release and forever discharge the Board of Trustees of the University of Illinois and the University of
Illinois at Springfield, their officers, agents and employees, from any and all claims, demands, actions or causes of action
arising from or by reason of any bodily injury or personal injury, known or unknown, death or damage to personal property
resulting from any accident which may occur as a result of participation in said placement and activities adjunct thereto, whether
by negligence or not. Further I state that I have carefully read this Release and know and understand its contents and sign this
Release as my own free and voluntary act.
______ International Students only: As an international student, I must be approved for Curricular Practical Training (CPT) by the
ISS office at UIS prior to beginning the Project experience. I must also submit the employer’s offer letter, which states
expected work load (number of hours per week not to exceed 20 per week during regular semesters and 40 hours per week
during summers) and start and end dates to the ISS office and IPL office. I am only allowed to participate in a maximum of
two internship/Project experiences, and only under extraordinary circumstances. Thus, only two CPT authorizations, which
cannot total one year of full time CPT.
I have fully read, understand, and agree to all of the above statements:
STUDENT SIGNATURE:______________________________________________________
DATE:___________________
Printed Name: ____________________________________________
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FIELD (ON-SITE) SUPERVISOR APPROVAL
As a Project Field Supervisor for a UIS Student, I understand (PLEASE INITIAL EACH STATEMENT):
______ I have reviewed students’ qualifications, selected a student, and assigned projects without regard to age, race, gender, national
origin, religion, disability, color, or marital status.
______ I agree to act as a Field Supervisor responsible for the mentorship of the student during the completion of the described
project. I also agree to discuss the student’s work with him/her and to provide feedback and suggestions as necessary.
______ I agree to report any changes, concerns, or questions I may have regarding the student or project experience directly to the
Internships and Prior Learning Services Office.
______ I agree that my relationship with the student will remain professional at all times.
______ I agree to provide performance feedback to my student throughout the project experience.
______ I will participate in a site visit or phone conference with the student and the student’s UIS supervisor about halfway through
the project work.
______ I understand I need to complete a Field Supervisor Evaluation near the end of the academic semester for which the student is
registered (UIS does not expect disclosure of proprietary company information).
______ Neither a relative of the student nor a current UIS student can serve as supervisor without prior approval by the IPL
Coordinator.
REQUIRED SIGNATURE. I have fully read, understand, and agree to all of the above statements:
Printed Name: _____________________________ Signature:____________________________________ Date:____________
UIS DEPARTMENT/SUPERVISOR APPROVAL
The STUDENT must have a faculty member* in his/her department endorse this project.
*Students in the following degree programs should have the faculty member listed approve/sign this form.
Psychology: Dr. Sheryl Reminger
Other departments: Identify your faculty advisor or a faculty member with whom you have taken courses or worked.
DEPARTMENT SIGNATURE
I agree that this student should complete the project, as presented on his/her project application, for his/her degree progress.
Printed Name: _____________________________ Signature:____________________________________ Date:____________
Please indicate whether or not you agree to be the UIS supervisor for this student's experience ♦: _____ YES _____ NO
♦
Does not apply to Computer Science or Criminal Justice department.
The UIS Supervisor has three duties:
1. To make one “site visit” (can be a conference call). The student is responsible for scheduling the site visit at a time convenient
for all. This should be done when no more than 40 to 50 percent of the clock hours have been completed.
2. To review and endorse the student's Learning Contract at or immediately after the time of the site visit.
3. To review and assess the completed project materials and endorse awarding the credit (or not).
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