Fillable Internship Verification Form printable pdf download

INTERNSHIP VERIFICATION FORM

Applicant’s Name ___________________________________________________________________________________

First

Middle Initial

Last

(Other name used)

INTERNSHIP INFORMATION (Use a separate sheet for each setting)

School District/Site Name _____________________________________________________________________________

School/Site Address _________________________________________________________________________________

Name of Field-Based Supervisor ________________________________________________________________________

Name of University-Based Supervisor ____________________________________________________________________

Start Date _____________ End Date _____________ Total Hours ______ Total school hours if different than total *______

THIS SECTION MUST BE COMPLETED BY UNIVERSITY AND FIELD-BASED SUPERVISORS (Supervisor for

school-based setting must be credentialed as a school psychologist in the state and setting in which the applicant completed the

internship.)

Did the intern receive an average of two hours per week of face-to-face supervision?

Yes

Did the intern successfully complete the internship?

Yes

The field-based supervisor:

is a credentialed school psychologist?

Yes

has worked as a school psychologist for at least three years prior

to the start of the applicant’s internship?

Yes

is licensed/certified to practice within the internship setting

if a portion is completed in a nonschool setting?

Yes

License/Certification Affiliation(s) and Number(s): ________________________

I certify that all of the above information on this verification form is accurate and true.

_________________________________________________________________________________________________

Internship Field-Based Supervisor Signature

Date

E-mail Address

_________________________________________________________________________________________________

University-Based Supervisor Signature

Date

E-mail Address

*Must equal 600 hours. Total internship hours must equal at least 1,200 hours. A school setting is defined by NASP standards as a setting in which the primary goal is the

education of P–12 students of diverse backgrounds, characteristics, abilities, disabilities, and needs. The school setting has available an internal or external pupil services unit that

includes at least one credentialed school psychologist and provides a full range of services. Other internship settings, if allowed by the program beyond the 600 hours in a school

setting, are consistent with program objectives and may include relevant school psychology activities in other educational contexts within, for example, hospitals, juvenile justice

institutions, and community agencies that provide collaborative services for schools.

Programs may allow up to half of the required 1,500 doctoral internship hours to be used from a prior, appropriately supervised specialist-level internship or equivalent

experience in school psychology if (a) the program determines that the specialist-level internship or equivalent experience meets program objectives and NASP standards for the

school psychology internship (see Standards 3.2 to 3.6), (b) candidates have met program objectives and criteria for school psychology specialist-level internship competencies,

and (c) any field experiences considered equivalent to a formal specialist level internship in school psychology are clearly articulated and systematically evaluated by the program.

Phone:

301-657-0270 or 866-331-6277 •

Web:

•

E-mail:

Internship Verification Form

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