Internship Proposal and Learning Contract - Psychology @ IUPUI

School of Science
Department of Psychology
School of Science Site Coordinator: Willow King-Locke, wkingloc@iupui.edu, 274-0704
Internship Proposal Form and Learning Agreement
Proposed semester for internship: Fall Spring Summer 1 Summer 2
Number of Credits: __________
Name: ____________________________________________ Student ID: ______________________________________
Email: __________________________________________
Address: ___________________________________________________________________________________________
Street City State Zip
Home Phone: _____________________________
Cell Phone: _____________________________
I affirm that The Department of Psychology may contact my employer to assess my progress. The information on
this form may be discussed.
SECTION 1: INTERNSHIP SITE INFORMATION – completed by the Site Supervisor
Company/Agency Name: _____________________________________________________________________________
Address: __________________________________________________________________________________________
Street City State Zip
Web Address: _______________________________________ Circle one : Public Private Non-Profit
Internship Site Supervisor: ___________________________________________ Title: ____________________________
Phone: _______________________________________ Email: ______________________________________________
Intern’s Title: ________________________________________ Hours per week: ________________ Salary: _________
Starting Date: __________________________________ Completion Date: ____________________________________
This student (check one):
is new to this job/agency.
is currently employed at this job/agency. How long?* _______________
has been previously employed at this job/agency. Dates?* ____________
*NOTE: if you checked one of the last two statements, the student must complete duties that are above and beyond
his/her current or previous duties. Academic credit may not be awarded for duties that are the same as duties
currently or previously completed.

SECTION 2: LEARNING AGREEMENT – completed by the student with Site Supervisor
GOALS AND LEARNING OBJECTIVES (Please attach a Job Description)
1. Describe the area of the organization will the intern be working?
2. What are the key goals for this internship (i.e., complete a specific project, assist in developing a program). Give
as much detail as possible.
3. What kind of training will the intern receive?
4. In what type of professional development activities will the intern have the opportunity to participate (i.e., staff
meetings, in-house seminars, or similar activities)?

5. How will the intern be made aware of the legal issues and/or ethical principles (e.g., confidentiality) that he or
she will be responsible for following, maintaining, or enforcing in the organization?
6. How often will the intern meet with the supervisor to discuss his/her progress? ___________________________
7. Identify the learning objectives for this experience. Learning Objectives can be best articulated by finishing this
statement, “After completing this internship, the intern will have learned/developed…”
8. Identify and describe a psychology-related topic you wish to explore through this internship. You will need to
generate an appropriate reading list to include academic journal articles or book chapters to reflect upon and
integrate into your experience and final paper.

STUDENT ACKNOWLEDGMENT:
I agree to:
• Adhere to all employer policies.
• Make every effort meet the Course Objectives and the site Learning Objectives during the internship.
• Notify the Internship Instructor of any changes to the internship, including a change in position, major
responsibilities, etc.
• Contact the Internship Instructor prior to early termination of the internship.
• The employer is under no obligation to hire me upon completion of the internship or graduation, nor am I
required to work for the employer upon completion of the internship or graduation.
• Complete all required coursework and site assignments.
Student Name:_________________ Student Signature:____________________ Date:__________
Employer Acknowledgment
I agree to:
• Provide a work environment which supports the Goals and Learning Objectives.
• Support and assist the student in completing their site assignments.
• Maintain a safe and healthy working environment.
• Set goals and objectives for the student.
• Evaluate the student’s job performance and provide constructive feedback.
• Complete the mid-term and end of semester employer evaluation.
Employer Name:_________________ Employer Signature:_____________________ Date:_____________
Final Approval Signatures Required
Final Approval Signatures Required
______________________________________________________
Student’s Signature
______________________________________________________
Site Supervisor’s Signature
______________________________________________________
Instructor’s Signature
____________________
Date
____________________
Date
____________________
Date
Submit completed form to Mikki Jeschke (LD 135) in order to receive permission to register for B421 Internship in Psychology.