HUSR Student’s Evaluation of Agency and Supervisor

1. Direction for Completing the Evaluation

Please answer all of the questions to the best of your ability. The entire survey must be completed at one sitting. You will NOT be allowed to partially save your work and return to it later.

NOTE: Provide your supervisor with the “End of the Semester Evaluation Verification” form that can be found on the HUSR Fieldwork Office’s website (under the Fieldwork Forms tab). Your supervisor and you will complete this form and turn it into your instructor at the end of the semester.

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* 1. Name of Agency:

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* 2. Please indicate the date you completed this survey.

Enter date according to this format, MM/DD/YYYY. (EX: 04/23/2015 would indicate April 23, 2015).

Date

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* 3. Name of Program:

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* 4. Agency Information:

Address:

Address 2:

City/Town:

State:

ZIP/Postal Code:

Phone Number:

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* 5. Name and Title of Internship Supervisor:

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* 6. Student Name:

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* 7. Semester/Year (EX: Spring/2015):

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* 8. Internship Placement Course Number:

396

495

496