Tel. 020-525 3003
(M – F 10:00 – 16:00)
Email: 4stages-cw-fmg@uva.nl
Student Desk
Nieuwe Achtergracht 166
1018 WV Amsterdam
OF AMSTERDAM
UNIVERSITY
College of Communication Science
INFORMATION ACCOMPANYING THE DEFINITIVE WORK PLACEMENT PROPOSAL
(Appendix F of the Work Placement Manual for the degree programme in Communication Science)
After completing and signing the statement on the back of this form, the form should be
submitted along with the definitive work placement proposal. See also the work placement
manual.
Personal information: Work placement student
Student number:
Surname
Given names
Address
Postal code and city
email
Telephone number and email address
2. Information on the work placement
Period from:
until (scheduled ending date):
Time division:
full time
part time
hours per week
Work load:
Who is the work placement supervisor from
Communication Science?
How many consultations with the supervisor have been planned?
(minimum 3)
3. Information on the work placement
institution
Name of work placement institution
Address
Postal code and city
Contact person/supervisor
Position:
Telephone number of the supervisor:
Frequency of:
4. Brief description of tasks
- supervision consultations between supervisor and work placement
student
- performance reviews
per
per
Please use this space to provide a brief description of the primary tasks, as specified
in detail in the definitive work placement proposal.
Continue on the other side
M&CI 12-3-2007
Please provide your student number on any communication with the UvA.
Continuation of Appendix F: Information accompanying the definitive work placement proposal
5. Definitive problem statement for the study to be
conducted
6. Statement of compliance
a.
b.
c.
d.
e.
The undersigned declare their agreement that the work placement student named in Section 1 on the other side of this form (hereafter,
‘the work placement student’), during the period stated in Section 2 on the other side of this form, shall perform work placement tasks as
described in Section 3 on the other side of this form, within the framework of the degree programme in Communication Science at the
University of Amsterdam, as specified in the ‘Definitive work placement proposal’, at the work placement institution named in Section 3 on
the other side of this form.
The work placement student, the work placement supervisor and the work placement coordinator shall be bound to secrecy with regard to
all confidential information obtained about the work placement institution within the context of the work placement.
Throughout the work placement period, the work placement student shall comply with the rules of the work placement institution and the
customary local practice, declare that he/she has and will retain proper personal liability insurance (AVP, previously WA).
The work placement supervisor expresses consent to the agreements made with regard to the substantive content of the work placement
and with the number of consultations with the work placement student, as specified on the other side of this form. Should the quality of
the work placement prove unacceptable, the work placement supervisor shall discuss this with the parties involved and have the option of
terminating or rejecting the work placement.
The supervisor shall be responsible for ensuring that the work placement student has the facilities needed during the work placement
period in order to perform the tasks of the work placement properly. The supervisor shall consent to and bear responsibility for the
supervision consultations and performance reviews specified on the other side of this form, and shall provide the work placement student
with the completed work placement completion form and a letter of reference upon completion of the work placement.
7. Signature of the work placement student
Name Date
Signature
8. Signature of the work placement supervisor
Name Date
Signature
9. Signature of the supervisor
Name Date
Signature
10. Signature of the work placement coordinator
Name Date
Signature
M&CI 12-3-2007
Please provide your student number on any communication with the UvA.