Department of Psychology
University of Arkansas at Little Rock
Stabler Hall 601 2801 S. University Ave
Little Rock, AR 72204
Phone: 501-569-3171
Fax: 501-569-3047
Internship Individualized Instruction Contract
Faculty Supervisor Name: ____________________________________________________________________
Student Intern Name: ________________________________________________________________________
Student Number: ___________________________________________________________________________
Student Address:
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Other student contact information:
Phone: ___________________________________________________________________________________
Daytime __________________________________________________________________________________
Evening __________________________________________________________________________________
Email: ___________________________________________________________________________________
Course number 3369 (three credit hours) section __________
Course number 3469 (four credit hours) section __________
Internship Application approved and on file with internship coordinator: ___ yes ___no
Internship Mentor Contract complete and on file with supervising faculty: ___ yes ___ no
Internship Site (as listed on Internship Application) ________________________________________________
Internship Mentor Name _____________________________________________________________________
Internship Mentor contact information___________________________________________________________
Prerequisites:
___yes ___no Overall GPA 3.0, psychology GPA 3.0
___yes ___no Junior or Senior status and completed course work appropriate to the project as determined by
the faculty supervisor and the internship mentor
Student Requirements:
___yes ___no That the project, or work plan, be defined well in advance of registration deadlines and be
acceptable to the student, the faculty supervisor, internship mentor, and the internship coordinator and is unpaid
throughout the internship.
___yes ___no A mid-semester report of student satisfaction and progress made (this may be formal or informal
at the discretion of your facultysupervisor) will be provided to the faculty supervisor from the student.
___yes ___no A mid-semester report will be provided to the faculty supervisor by the internship mentor (this
may be formal using the Mid-Term Internship Mentor Feedback Form or informal at the discretion of your
faculty supervisor); the student will facilitate this process as needed.
___yes ___no An End-Term Internship Mentor Feedback Form will be submitted from the internship mentor;
student will facilitate this process as needed.
___yes ___no A final report submitted by the first day of finals (this should be a formal paper of at least 1000
words in length, APA style) to your faculty supervisor.
___yes ___no A written logbook documenting total hours worked submitted to your faculty supervisor by the
first day of finals signed/initialed by the internship mentor.
___yes ___no 3 credits, 100 hours minimum of documented work
___yes ___no 4 credits, 120 hours minimum of documented work
___yes ___no Internship will be unpaid.
Other requirements:
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Supervising Faculty Signature ________________________________________________________________
Student Intern Signature _____________________________________________________________________
Date ___________________