Psychology student internship contract



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Department of Psychological and Brain Sciences rev. 07.16c:\users\marian\appdata\local\microsoft\windows\inetcache\content.word\umass seal (cmyk-black)8@300.jpg

University of Massachusetts Amherst

PSYCHOLOGY STUDENT

INTERNSHIP CONTRACT

Instructions. Fill out the first two pages of this form in consultation with your on – site Internship Supervisor. To it, attach a signed copy of the Professionalism, Confidentiality, and Respect Policies and a copy of the face sheet for your Malpractice Insurance, purchased at this site: http://locktonmedicalliabilityinsurance.com/coverage/counselors-and-therapists-liability-insurance/. BRING THIS COMPLETED CONTRACT WITH BOTH ATTACHMENTS to Prof. Marian MacDonald (Tobin 614), who will serve as your Faculty Sponsor for this Internship, for her approval. If you are taking this Internship as PSY 398, Prof. MacDonald will register you; if you are (or are also) taking this Internship as UMASS 298, you must register yourself using CAREER CONNECT (https://www.umass.edu/careers/log-umass-amherst-careerconnect).

Name: __________________________________________ SPIRE No.: _____________________

Email address: _____________________________ Cell phone No.: _________________________

Standing During Semester of Internship: □ Junior □ Senior Current GPA: ______ (3.0 Required)

Note. A maximum of 18 credits from courses ending with the numbers 98 can be applied toward the 120 credit graduation requirement; this includes all TAships, RAships, and Internships.

How many credits have you already earned for courses ending with the numbers 98? ______

To be approved for an Internship, you must secure the signature of a UMass Faculty Member or Graduate Student who will be a character reference for you. Ask that person to sign this statement (see http://jobsearch.about.com/od/jobsearchglossary/g/character-reference.htm):

I am able to serve as a character reference for the student named above to do an Internship.

Signature: _____________________________ Printed Name: _______________________________






ABOUT YOUR INTERNSHIP SITE AND SUPERVISOR:

Internship Agency/Program Name: ____________________________________________________

Street Address: ___________________________________________________________________

City: _______________________________ State: ______ Telephone: _____________________

Your Service Site Location: _________________________________________________________

Your Direct Supervisor’s Name: ______________________________________________________

Title: ____________________________________________________________________________

Email address: ____________________________________ Telephone: _____________________




ABOUT THE DETAILS OF YOUR INTERNSHIP:

This Internship is to be taken as (check one):

PSY 398 for 3 credits and/or □ UMass 298 for _____ credits

Start Date: ____________ End Date: ___________ for a total of ________ on – site hours.

Weekly On – Site Schedule: ___________________________________________________

Note. Scheduled hours missed for any reason, including illnesses or UMass holidays or vacations, must be made up, since to receive academic credit you must complete the required number of on – site hours. Arrangements for making up missed hours must be made in consultation with your on – site Direct Supervisor.

Primary Duties: ______________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Nature of Supervision (check all that apply): □ Individual □ Group □ In – service Trainings

Frequency of Supervisory Sessions: __________ Length of Supervisory Sessions: _______

On – site Supervisor’s Signature: ______________________________ Date: ____________




Memorandum of Understanding

I understand that this Practicum will be graded pass – fail, and that to receive credit for this practicum I must:





  1. Receive a satisfactory End – of – Term Evaluation from my on – site Direct Supervisor;

  2. Complete 40 hours of work on – site for each credit I receive for this course;

  3. Pass a CORI check prior to the start of my Internship;

  4. Purchase Malpractice Insurance prior to the start of my Internship;

  5. Submit an electronic Internship Activities and Reflections Report weekly (using the template attached) to Prof. Marian L. MacDonald at macdonal@psych.umass.edu;

  6. Submit an 8 – 10 page paper copy final paper on “What I Learned from My Internship,” along with a completed End – of – Term Internship Site Assessment form, to Prof. Marian L. MacDonald by the second scheduled day of exams, and;

  7. Adhere to the Professionalism, Confidentiality, and Respect Policies understood as governing my conduct in connection with this Internship.


I have read, and agree to

meet, these conditions: __________________________________ _____________

Student Intern’s Signature Date

I approve, and agree to sponsor,

the Internship described above: _______________________________ ____________

Faculty Sponsor’s Signature Date

Psychological and Brain Sciences revised 07.16 UMass Amherst

Internship Activities and Reflections Report

[Note. Please do not exceed the space allowed for each section.]

Name: _________________________________ Internship Site: ________________________________________

For the week ending: ____________ Hours on site this week: ____ Cumulative Hours on site this semester: _____

Provide a summary of your activities this week:

Describe two events you observed this week that made a strong impression (positive or negative) on you.

Provide a brief summary of the content of the supervision you received, or the training activities in which you participated, this week.

Make a bullet list of the lessons you learned in your Internship this week (including lessons you learned about yourself).

Provide the link to, and a brief summary of, one empirical or review article from an APA journal you read this week that is relevant to your Internship work or site. Include a one - sentence statement of the article’s “take home message” in your own words, written as if you were going to give it to the staff at your site.



Department of Psychological and Brain Sciences rev. 07.16c:\users\marian\appdata\local\microsoft\windows\inetcache\content.word\umass seal (cmyk-black)8@300.jpg

University of Massachusetts Amherst


Statement of

Professionalism, Confidentiality, and Respect Policies

Governing the Conduct of UMass Amherst

Psychology Student Interns

Taking PSY 398 and UMass 298
I agree to abide by these Professionalism, Confidentiality, and Respect policies for this Internship. I understand that I am to conduct myself as a professional at all times, especially when in my Internship setting. I understand that I am to take great care to protect the confidentiality and anonymity of patients/consumers/clients/students when discussing my Internship activities in any setting, and that I am not to engage in any such discussions unless those discussions can reasonably be expected to directly benefit the patients/consumers/clients/students I discuss. Furthermore, I understand that acting professionally means (1) treating supervisors, co – workers, and especially patients/consumers/clients/students with respect, (2) following the policies and procedures of my Internship setting, (3) completing necessary documentation completely, accurately, and in a timely fashion, (4) remaining accountable for my actions, (5) honoring the confidentiality of all clinical and professional material, (6) valuing diverse cultures and opinions, (7) consulting with my Internship site supervisor and my University sponsor appropriately, and most certainly whenever in doubt about how to handle a practical situation, and (8) behaving in accord with the ethical principles of the American Psychological Association (http://www.apa.org/ethics/code/principles.pdf).
I have read the Ethical Code of the American Psychological Association. Furthermore, I understand this Statement of Professionalism, Confidentiality, And Respect Policies and, on my honor, I agree to abide by these policies.

__________________________________ _____________

Student Intern’s Signature Date

careerservices-header7-15

Field Experience Program



University of Massachusetts – 511 Goodell Building, Amherst, MA 01003 Tel. 413-545-6265 Fax 413-545-4426

Final Evaluation from Supervisor
Student: ___________________________________________ID#___________________________________
Supervisor’s name: _________________________________________________________________________
Organization name: ________________________________________________________________________
Address: _________________________________________________________________________________
E-mail address/phone: ______________________________________________________________________

Thank you for working with the above student. Please take a few moments to fill out this evaluation. It will be kept in the student’s file and may be accessed by the student at any time.
Student Information

  1. Please describe specific projects performed by the student:




  1. Please rate the student’s abilities in the following areas:

(1=Outstanding, 2=Very Good, 3=Average, 4=Marginal, 5=Unsatisfactory, NB=No basis for evaluation)
Outstanding VG Average Marg. Unsat.

Overall evaluation of student's performance 1 2 3 4 5 NB

Ability to apply classroom knowledge to actual practice 1 2 3 4 5 NB

Works as part of a team 1 2 3 4 5 NB

Communicates well through speaking 1 2 3 4 5 NB

Communicates well in writing 1 2 3 4 5 NB

Demonstrates initiative 1 2 3 4 5 NB

Demonstrates follow-through on projects 1 2 3 4 5 NB

Demonstrates an ability to think critically 1 2 3 4 5 NB

Seeks creative solutions to work challenges 1 2 3 4 5 NB

Demonstrates effective organizational skills 1 2 3 4 5 NB

Demonstrates effective time management skills 1 2 3 4 5 NB

Demonstrates an ability to work well with diverse populations 1 2 3 4 5 NB

Demonstrates ability to solve problems 1 2 3 4 5 NB

Demonstrates computer skills 1 2 3 4 5 NB

Demonstrates a mastery of technical and electronic systems 1 2 3 4 5 NB
Comments
Please list any other competencies you have observed.


  1. Are there specific areas of improvement that you feel the student should be aware of? Please describe.



  1. If giving a grade, what would you give this student based on his/her performance during the internship?


(A=Superior, B=Very Good, C=Average, D=Minimal Effort, F=Failure) __________________
Yes,_______I have discussed this evaluation with the student intern. No,________I have not.
Program Information


  1. How would you rate your satisfaction with the UMASS Amherst Field Experience Program?

(1=Outstanding, 2=Very Good, 3=Average, 4=Marginal, 5=Unsatisfactory, NB=No Basis)
1 2 3 4 5 NB
Comments:

  1. Would you like to add/maintain a position listing with our office? yes no



  1. Are there specific needs for student interns that your organization is anticipating for the upcoming year?

CERTIFICATION OF PARTICIPATION:
Upon successful completion of their Field Experience placements and submission of all required reports, University students receive official recognition of the experience on their academic transcripts. It is very important to the student, therefore, that we receive the following information:
Exact employment dates: __________________ to ______________________

(month/day/year) (month/day/year)


Total number of hours worked ________
_________________________________________ _____________________

Supervisor’s signature Date

(Form Revised8/2014)
Department of Psychological and Brain Sciences rev. 07.16c:\users\marian\appdata\local\microsoft\windows\inetcache\content.word\umass seal (cmyk-black)8@300.jpg

University of Massachusetts Amherst

INTERNSHIP SITE and SUPERVISOR

FINAL ASSESSMENT

Intern’s name: ___________________________________ Today’s Date : ___________

Internship Site: ____________________________________________________________

I have discussed or will be discussing this Assessment with my on – site Supervisor.

I have not and will not be discussing this Assessment with my on – site Supervisor.





Extremely

Close Match

Moderately

Close Match

Slightly

Close Match

Slight

Mismatch

Moderate

Mismatch

Extreme

Mismatch



















How closely did your Internship

experience match what you

expected when you first set it up?

Extremely

Well

Moderately

Well

Slightly

Well

Slightly

Poorly

Moderately

Poorly

Extremely

Poorly



















How well did your initial on – site

orientation / training prepare you

for the work you were expected to

do on your Internship?



Extremely

Valuable

Moderately

Valuable

Slightly

Valuable

Slightly

Useless

Moderately

Useless

Extremely

Useless



















Taking everything into account,

how valuable was your Internship



experience overall to your Career

Development?

What did you MOST LIKE about your Internship experience?

page 1 of 4

What did you MOST DISLIKE about your Internship experience?


Extremely

Enthusiastically



Moderately Enthusiastically

Slightly

Enthusiastically



Would Not

Recommend















How enthusiastically would you

recommend this Internship Site to

a prospective Intern?

What concrete, specific suggestions do you have for improving the Internship experience at this site for the next Intern?

page 2 of 4

Who was your direct on – site supervisor? ___________________________________________

Please rate this person on the rating scales below, using these ratings:

1 = Outstanding

2 = Very Good

3 = Adequate

4 = Marginal

5 = Unsatisfactory

NB = No basis for evaluation




1

2

3

4

5

NB

1. Conducted him/herself in a professional manner.



















2. Was a good listener



















3. Was good at giving me feedback



















4. Was open to my ideas and opinions



















5a. Was thoughtful and considerate of me



















5b. Was thoughtful and considerate of regular staff

members




















5c. Was thoughtful and considerate of the people

the site served





















6. Had good self-control under pressure



















7. Would admit it or apologize when wrong



















8. Was punctual



















9. Left personal affairs at home



















10. Gave me compliments and positive feedback



















11. Regularly provided me with on–the–job training



















12. Willingly answered my questions



















13. Let me know in a fair, timely, and constructive

manner when I did something wrong





















14. Kept his/her promises to me



















15. Exercised good judgment in giving me

responsibilities, always making sure that I

remained challenged, but not giving me tasks for

which I was insufficiently prepared.





















16. Served as a good mentor to me.



















17. Served as a good role model for me.



















page 3 of 4

What were your direct Supervisor’s greatest strengths?

What is one change you would suggest in your Supervisor’s style that you think might make him or her better Supervisor for Interns?

The information you have provided in this Final Assessment will NOT be given to your Internship site or Supervisor WITHOUT YOUR EXPRESS PERMISSION. If you have not or will not be discussing this Final Assessment with your site supervisor, please indicate below what you would like us to do with this information.

□ I would like a copy of this Final Assessment to be given to (choose one or both)

□ my Internship Site □ my Direct Supervisor

□ I would like selected portions of this Final Assessment (the ones I have



highlighted) to be given to (choose one or both)

□ my Internship Site □ my Direct Supervisor

□ I am providing this information only to complete the course requirements for PSY 398 /

UMass 298, and I do not want any of it disclosed to my Internship Site or Site



Supervisor.

Please sign and date here: ______________________________ ____________ , 20 ___



Thank you for completing this Final Assessment. What you have shared will help us strengthen the Internship Program.

page 4 of 4

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