Kinesiology Independent Study (KIN 286 – OFF CAMPUS)
KIN 286, Independent Study
Independent study through projects or directed reading related to the field of Kinesiology. May
be repeated for a total of 6 units. Prerequisites: Graduate Standing.
Notes:
• Use this registration form only for an independent study off-campus with a community group/agency.
• For off-campus work at a community agency/site you need to complete the forms that follow and the
University – Organization Contract.
• You MUST do the independent study DURING the semester in which you are registered, and it must
NOT continue outside that time.
• If you are interested in an on-campus independent study (e.g., research) you should complete an ON
CAMPUS KIN 286 registration form (located on the forms page of the KIN website).
Course Objectives:
Independent study (e.g., research, community work) related to the field of Kinesiology enables
the student to develop in depth knowledge and skills to complement academic coursework and
achieve the department’s program learning outcomes.
Grading:
Credit (CR)) or No Credit (NC) will be determined based on requirements specified by your Kinesiology
independent study supervisor.
Good resources when looking and preparing for a fieldwork-type independent study are on the SJSU
Career Center’s web site:
http://www.sjsu.edu/careercenter/students/find-a-job-internship/index.html
http://www.sjsu.edu/careercenter/students/internship-resources/index.html
Instructions For Students
Here you will find the KIN forms you will need to complete related to your OFF CAMPUS independent
study. In addition, you will need to have your off campus site owner/manager sign a University Organization Contract (UOC) if one does not already exist. You can check here to see a list of
organizations SJSU already has a contract with: http://www.sjsu.edu/kinesiology/internships/.
When all forms are complete turn them in to the Kinesiology main office. The internship manager will
review the UOC and, assuming there are no problems, forward your paperwork to the graduate program
coordinator who will conduct a final review of your proposed independent study. Upon final approval,
Kinesiology staff will contact you with add code information.
Step 1: Complete internship registration form, internship specifications form, and internship participation
guidelines form.
KIN 286, Independent Study Registration Form: This is the form that is used to obtain an add code so
you can enroll in this course. You can type in or hand write the information requested on this form.
• At the top, provide the contact information requested.
• In the middle section, provide confirmation that you meet and understand requirements by
checking the boxes provided. Also provide a brief description of what your independent study
entails.
• Obtain the signature of your KIN supervisor for the independent study, then sign your name and
date.
Off Campus ‘Fieldwork’ Specifications Form: This form constitutes the agreement between you and
your off campus site supervisor with regard to learning outcomes and activities you’ll be engaged in. You
can type in or hand write the information requested on this form.
• At the top provide a start date, end date, and number of hours to be completed. Note: you cannot
technically be doing fieldwork outside the official dates of a given semester.
• Next, provide three learning outcomes. Put here a description of what you will learn as a result of
the internship experience (not the activities you will do).
• Next, provide a brief description of the activities you will be doing - up to a maximum of 8
(minimum 4).
• At the bottom, your site supervisor prints and signs name, date, and title; your KIN independent
study supervisor signs and dates, then you sign and print your name and date.
Before turning in all forms, make 3 copies of this page – one for you and one to give to your site
supervisor and KIN independent study supervisor.
Participation Guidelines: This form provides guidance on expectations of you throughout the time of
your internship. You can type in or hand write the information requested on this form.
• Provide at the top in the spaces provided, information on hours and dates of internship.
• Print and sign your name at the bottom of the page and provide date.
Step 2: Have the manager/owner at your site complete a University - Organization Contract (UOC) if one
does not already exist. Note: It is quite likely that the person who needs to complete and sign the contract
will be the owner/manager/director of the organization and not necessarily your site supervisor. The
person with signature authority on formal contracts is the person the UOC needs to be signed by.
University – Organization Contract (UOC): This document is the formal contract between SJSU and
the site where you are doing your off campus work. You can obtain the UOC from the KIN internships
web page The most expedient way to get this completed is to email the document and instructions (found
on the KIN internships web page) to the person at your site who has signature authority on contracts.
http://www.sjsu.edu/kinesiology/internships/
San José State University Kinesiology Department
Off-Campus (fieldwork) KIN 286 Independent Study Registration Form
Student Name
Student Address
Student Email Address
Student Phone
Student Concentration
Student ID #
Emergency contact:
name, phone, relationship
to student
Fieldwork Site Name
Site supervisor Name &
Email
# Units Requested
Students, please note: The signature you provide constitutes confirmation that:
❒
You have graduate standing
❒
You have read the KIN 286 syllabus and understand all guidelines and requirements
❒
You will complete a minimum of 50 hours at your fieldwork site for each unit enrolled
❒
You have attached a contract for your site OR ❒ A contract already exists (or is not needed)
Brief description of independent study/fieldwork: ____________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Evaluation: Based on site supervisor’s assessment of performance and review by your Kinesiology
independent study supervisor.
_________________________________________
Student Signature
___________
Date
_________________________________________
KIN Independent Study Supervisor Signature
___________
Date
_________________________________________
KIN Internship Manager Signature (Shifflett)
___________
Date
_________________________________________
KIN Graduate Coordinator Signature (Butryn)
___________
Date
Class Code: _______________ Permission Code: _________________ Date: ________
Fieldwork Specifications
Students: Complete this form in consultation with your site supervisor and provide your site supervisor
and KIN independent study supervisor with a copy.
Start Date:
________
End Date:
_________
# Hours: _______
Identify 3 learning outcomes expected:
1.
2.
3.
Summary of planned activities: (List up to 8)
1.
5.
2.
6.
3.
7.
4.
8.
_____________________________________
Site Supervisor’s Signature
_______________________________
Date
_____________________________________
Print Site Supervisor’s Name
_______________________________
Site Supervisor’s Title
_____________________________________
Student's Signature
_______________________________
Date
_____________________________________
Student's Name (print)
_____________________________________
Kinesiology Faculty Independent Study Supervisor
_______________________________
Date
______________________________________
KIN Graduate Coordinator Signature (Butryn)
___________
Date
INTERNSHIP/FIELDWORK PARTICIPATION GUIDELINES
1. I will devote ______ hours per week towards completion of the service and learning objectives
listed in my learning plan (internship/fieldwork specifications form) for a total of _______
service hours, effective from ____________ to ____________. I agree to complete all paperwork
required by my department or site supervisor as part of this learning (internship/fieldwork)
experience.
2. I understand and acknowledge that there are potential risks associated with this learning
(internship/fieldwork) experience, some of which may arise from (a) my assigned tasks and
responsibilities, (b) the location of the learning site, (c) the physical characteristics of the learning
site, (d) the amount and type of criminal activity or hazardous materials at or near the location of
the learning site, (e) any travel associated with the learning site, (f) the time of day when I will be
present at the learning site, (g) the criminal, mental and social backgrounds of the individuals I
will be working with or serving, and (h) the amount of supervision I will receive. I further
understand and acknowledge that my safety and wellbeing are primarily dependent upon my
acting responsibly to protect myself from personal injury, bodily injury or property damage.
3. Being aware of the risks inherent in this learning experience (internship/fieldwork), I nonetheless
voluntarily choose to participate in this learning experience. I understand that I may stop
participating if I believe the risks become too great.
4. While participating in this learning experience (internship/fieldwork), I will (a) exhibit
professional, ethical and appropriate behavior; (b) abide by the learning site’s rules and standards
of conduct, including wearing any required personal protective equipment; (c) participate in all
required training; (d) complete all assigned tasks and responsibilities in a timely and efficient
manner; (e) request assistance if I am unsure how to respond to a difficult or uncomfortable
situation; (f) be punctual and notify the learning site if I believe I will be late or absent; and (g)
respect the privacy of the learning site’s clients.
5. While participating in this learning experience (internship/fieldwork), I will not (a) report to the
learning site under the influence of drugs or alcohol; (b) give or loan money or other personal
belongings to a client; (c) make promises to a client I cannot keep; (d) give a client or
representative a ride in my personal vehicle; (e) engage in behavior that might be perceived as
harassment of a client or learning site representative; (f) engage in behavior that might be
perceived as discriminating against an individual on the basis of their age, race, gender, sexual
orientation, mental capacity, or ethnicity; (g) engage in any type of business with clients during
the term of my placement; (h) disclose without permission the learning site’s proprietary
information, records or confidential information concerning its clients; or (i) enter into personal
relationships with a client or learning site representative during the term of my placement. I
understand that the learning site may dismiss me if I engage in any of these behaviors.
6. I agree to contact the Director at the University’s Center for Community Learning and Leadership
(CCLL) at 408-924-5440 if I believe I have been discriminated against, harassed or injured while
engaged in this learning activity.
7. I understand and acknowledge that neither the University nor the learning (internship/fieldwork)
site assumes any financial responsibility in the event I am injured or become ill as a result of my
participating in this learning experience. I understand that I am personally responsible for paying
any costs I may incur for the treatment of any such injury or illness. I acknowledge that the
University recommends that I carry health insurance.
Student Name (print) __________________________________________________
Student Signature
__________________________________________________
Date:
_________________