San José State University Kinesiology Department
Form for APE (170C) and PE Students (172, 178, 179)
Needing a University-Organization Agreement
This form is used when your fieldwork and/or observations are done at a location where there is
not yet a contract between the site of your fieldwork/observation and SJSU. Please complete this
form and attach it to the front of your UOA (University-Organization Agreement). The UOA form
can be found here: http://www.sjsu.edu/kinesiology/internships/
Please bring the forms to the KIN main office and ask the staff to put them in Dr. Shifflett’s mailbox. Dr.
Shifflett will review then forward the UOA to SJSU’s contracts office and notify your instructor that the
UOA has been taken care of.
Student Name
Student
Emphasis/Specialization Area
Student ID #
Student email address
Signatures Needed:
_________________________________________
Kinesiology Fieldwork Supervisor (Schmidlein/Megginson)
___________
Date
_________________________________________
Kinesiology Internship Manager (Shifflett)
___________
Date