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1 UNDERGRADUATE CONTENTS: 1. Undergraduate Internship Program Description 2. Application for an Undergraduate Intern Form 3. Internship Agreement Form 4. Letter to Placement Employers 5. Student Declaration of Understanding 6. Pre-placement Safety Orientation Checklist 7. Internship Learning Objectives Form 8. Intern s Weekly Log Book Form (sample page) 9. Intern s Mid-Term Performance Appraisal Form 10. Intern s Final Performance Appraisal Form 11. Intern s Guidelines for Preparing the Final Report 12. Intern s Evaluation of the Agency 13. Intern s Evaluation of the Agency Supervisor Further Information: Undergraduate Internship Program Faculty of Human Kinetics Department of Kinesiology University of Windsor Windsor, ON N9B 3P4 Phone: (519) Ext Fax: (519)

2 Undergraduate Internship Program Description What: Purpose: A supervised,field-work experience in an approved, Undergraduate work setting and open exclusively to Undergraduate majors (offered as a one course equivalent on a Pass/Non-Pass basis). (9 hours per week). The Undergraduate Internship Program is designed to provide students with the opportunity to enrich their classroom studies with a structured experientially-based field-work experience. Interns must be given the opportunity to: 1. Learn current methods from expert practitioners 2. Apply learned theoretical content in a practical Undergraduate-based setting 3. Measure and evaluate their skill set and knowledge base relative to the needs of the field 4. Explore a potential Undergraduate career option 5. Gain a greater appreciation for the role and function of Undergraduate professionals Student Eligibility: Candidates must be Year III or IV Kinesiology students enrolled in the Undergraduate major. Co-operating Professional Eligibility: Process: Professionals in the Undergraduate field who agree to provide an enriching learning opportunity for a student. The host agency must agree to provide the necessary space and equipment required for the student to carry out his/her duties and agree to supervise, support and evaluate the Undergraduate intern. 1. Students are available during any one of the three academic terms (Fall, Winter, or Summer). 2. All internship experiences must be formally approved in advance (the student, co-operating professional and a faculty member from the Department of Kinesiology must sign the Internship Agreement Form. 3. Employers are encouraged to post an internship opportunity by completing an Application for a Undergraduate Intern Form and forwarding it to the Department of Kinesiology. 4. Students can uncover their own internship opportunities provided all parties sign the Internship Agreement Form prior to the commencement of the internship experience. 2

3 Evaluation: Students will be evaluated on the following basis: 1. Satisfactory completion of an Internship Weekly Log Book. 2. Satisfactory completion of the Internship Learning Objectives Form. 3. Satisfactory completion of an Internship Final Report. 4. Submission of a Undergraduate Internship Mid-Term Performance Appraisal Form 5. Satisfactory grade on the Undergraduate Final Evaluation Form. Further information: Undergraduate Internship Program Department of Kinesiology University of Windsor Windsor, ON, Canada Phone: (519) ext Fax: (519)

4 Application for a Undergraduate Intern Form (Please review the Program Description prior to completing this form) FAX Number: Please indicate the term of interest: Fall Term (September December) Winter Term (January April) Summer Term (May August) Student Name: Student ID: Name of the Organization: Name of Cooperating Professional: Mailing Address: City: Code: Contact Person: Contact Phone: FAX: Intern Job Title: Intern s Responsibilities: Pay (optional) if applicable: Special Skill Requirements/Certifications: Please return the completed form to: Undergraduate Internship Program Department of Kinesiology University of Windsor Windsor, ON, Canada N9B 3P4 Phone: (519) FAX: (519)

5 Internship Agreement Form I, (Name and Student ID#) am a senior undergraduate student (Year III or IV in the Department of Kinesiology. I agree to use my uwindsor.ca address: I agree to serve as a Undergraduate intern at under the supervision of. Section to be completed by the co-operating professional: Student Job Title: Hours per week: (must average to 9 hrs/week for the 13 week term): Please check: Term: Fall: ; Winter: ; Summer: Paid (optional): Not Paid: Position responsibilities: (Please attach) Other conditions of internship experience: (Please attach) The undersigned agree to the above conditions: Student Intern Date Co-operating Professional Agency: Address: Phone: Date FAX: University Supervisor Date Note: This form must be completed and signed prior to the commencement of the Internship experience. 5

6 Letter to Placement Employers Process for Workplace Insurance for Postsecondary Students on Unpaid Work Placements The Ministry of Training, Colleges and Universities (MTCU) has implemented a new process for students enrolled in an approved Ontario university program that requires them to complete placements in a workplace as part of their program of study. The Government of Ontario, through the Ministry of Training, Colleges and Universities (MTCU), pays the WSIB for the cost of benefits provided to Student Trainees enrolled in an approved program at University of Windsor and participating in unpaid work placements with employers who are either compulsorily covered or have voluntarily applied to have Workplace Safety and Insurance Board (WSIB) coverage. MTCU also covers the cost of private insurance with ACE-INA Insurance for Student Trainees enrolled in an approved program at University of Windsor and participating in unpaid work placements with employers that are not required to have compulsory coverage under the Workplace Safety and Insurance Act. The Workplace Educational Placement Agreement (WEPA) Form has been replaced by the Postsecondary Student Unpaid Work Placement Workplace Insurance Claim Form. Placement Employers and Training Agencies (universities) are not required to complete and sign the online Postsecondary Student Unpaid Work Placement Workplace Insurance Claim Form for each placement that is part of the student s program of study in order to be eligible for WSIB coverage. Instead, this form only needs to be completed when submitting a claim resulting from an on-the-job injury/disease. Please note that universities will be required to enter their MTCU- issued Firm Number in order to complete the online claim form. The MTCU Guidelines for Workplace Insurance for Postsecondary Students of Publicly Assisted Institutions on Unpaid Work Placements and the new claim form are posted on the Ministry s public website at: (English) or (French). Please note that all WSIB or ACE-INA Insurance procedures must be followed in the event of an injury/disease. Declaration By signature of an authorized representative, the Placement Employer hereby agrees to the following: That it will immediately report to the University any workplace injury or disease involving a student on an unpaid work placement. Where the Placement Employer is covered by the WSIB, the Placement Employer will comply with all WSIB reporting procedures. If the Placement Employer is not covered by the WSIB, then it will comply with the ACE-INA reporting procedures found in the MTCU Guidelines for Workplace Insurance for Postsecondary Students of Publicly Assisted Institutions on Unpaid Work Placements. When the Placement Employer is covered under the Workplace Safety and Insurance Act, a Form 7 will be completed and submitted to the University within three days of learning of a work related accident. The Placement Employer agrees to complete a Letter of Authorization to Represent the Placement Employer and to provide it to the University along with the completed Form 7. 6

7 The Placement Employer agrees that it will provide the Student Trainee with health and safety training and take appropriate precautions to ensure that the Student Trainee is supervised in order to protect the Student Trainee from health and safety hazards that may be encountered at the placement organization. The Placement Employer agrees to provide written confirmation that the Student Trainee has received the appropriate health and safety training. In the event of a claim, the Placement Employer agrees that it will review the Student Trainee s restrictions and, where possible, modify the program as required in order to accommodate the Student Trainee to facilitate return to the program. Organization: Title: Date: Signature: Employer s organization is covered under the Workplace Safety & Insurance Board? Yes No A signed copy of this document is to be returned to the University of Windsor placement coordinator, prior to the commencement of the work/education placement, and a copy is to be kept by the placement employer. Placement Coordinator: Chad Sutherland, Applied Learning Coordinator University of Windsor Department of Kinesiology Human Kinetics Building, Room Sunset Ave. Windsor, ON N9B 3P4 7

8 Student Declaration of Understanding Workplace Safety and Insurance Board or Private Insurance Coverage For Students on Program Related Placements Student coverage while on unpaid placement: The government of Ontario, through the Ministry of Training, Colleges and Universities (MTCU), reimburses WSIB for the cost of benefits it pays to Student Trainees enrolled in an approved program at a Training Agency (university). Ontario students are eligible for Workplace Safety Insurance Board (WSIB) coverage while on placements that are required by their program of study. MTCU also provides private insurance through ACE-INA to students should their unpaid placement required by their program of study take place with an employer who is not covered under the Workplace Safety and Insurance Act and limited coverage where placements are arranged by their postsecondary institution to take place outside of Ontario (international and other Canadian jurisdictions). However, students are advised to maintain insurance for extended health care benefits through the applicable student insurance plan or other insurance plan. Please be advised that the University of Windsor will be required to disclose personal information relating to the unpaid work placement and any WSIB claim or ACE-INA claim to MTCU. This Agreement must be completed, and signed to indicate the Student Trainee s acceptance of the unpaid work placement conditions, and a copy provided to the University of Windsor placement coordinator prior to the commencement of the work placement. Declaration: I have read and understand that WSIB or private insurance coverage will be provided through the Ministry of Training, Colleges and Universities while I am on a placement as arranged by the university as a requirement of my program of study. I agree that, over the course of my placement, I will participate in and implement all safety-related training and procedures obtained from the University and the Placement Employer. I will provide the University with written confirmation that I have received safety training. I will promptly inform my Placement Employer of any safety concerns. If these concerns are not resolved, I will contact the University s placement coordinator within my faculty and notify them of any unresolved safety concerns. I understand that all accidents sustained while participating in an unpaid work placement must be immediately reported to the Placement Employer and my University of Windsor placement coordinator. An MTCU Postsecondary Student Unpaid Work Placement Workplace Insurance Claim form must be completed and signed in the event of injury and submitted to the University placement coordinator. In the event of an injury, I also agree to maintain regular contact with the University and to provide the University with information relating to any restrictions and my ability to return to the placement. I understand the implications and have had any questions answered to my satisfaction. 8

9 Student Name: Program: Student Signature: Date: Organization: Total Placement Hours: Visa Student? Yes No Parent/Legal Guardian s Name (for student less than 18 years of age) please print: Signature: Date: A signed copy of this document is to be returned to the University of Windsor placement coordinator, prior to the commencement of the work/education placement, and a copy is to be kept by the placement employer. Placement Coordinator: Chad Sutherland, Applied Learning Coordinator University of Windsor Department of Kinesiology Human Kinetics Building, Room Sunset Ave. Windsor, ON N9B 3P4 9

10 SAFETY ORIENTATION CHECKLIST Placement Employer: This checklist may be used to document health and safety orientation provided to a student(s) prior to exposure to any hazards in your workplace. This checklist, or another format documenting orientation, must be returned to the University of Windsor placement coordinator. Student Name: Student Number: Organization Name: COMPLETE DURING ORIENTATION! Name of immediate supervisor and Joint Health and Safety Committee representative (JHSC) or Safety Representative Worker/supervisor rights and responsibilities Safe work procedures and operation of equipment Use of Personal Protective Equipment (PPE) Identification of restricted or prohibited areas, tools, equipment and machinery Hazards in the workplace that may affect the student, how they re controlled and how to deal with them What to do and who to see if the student has a safety concern What to do when there is a fire or other emergency (e.g., evacuation procedures) Location of fire exits and fire extinguishers Location of the first aid supplies, equipment, facilities: Names of staff responsible for first aid How to record first aid treatment Procedures for reporting accidents and injuries Workplace Hazardous Materials Information System (WHMIS) Workplace policies and procedures on: Workplace Harassment Violence prevention Working in isolation Smoking/Drinking/Substance abuse Location of other important information Materials Safety Data Sheet (MSDS) Joint Health & Safety Committee Minutes Instructions for safe operation of each piece of equipment (if applicable) Important telephone numbers Other hazards covered during orientation should be documented and attached on an additional sheet. Signatures Supervisor Name Signature Date Student Signature Date 10

11 INTERNSHIP LEARNING OBJECTIVES Student s Name: Term: Agency: Employer s Signature: Directions: a) Please complete the following three sections. b) Forward the completed form to the Department of Kinesiology by the end of the second week of the internship experience. c) Please prepare these objectives in consultation with your Cooperating Professional. SECTION A: Technical skills and competencies you hope to heighten (e.g., skills related to the technical aspects of your position) SECTION B: Interpersonal skills that you hope to enrich through your internship (e.g., leadership skills, communication skills, etc.) SECTION C: SUMMARY STATEMENT: Please provide a one-sentence summary outlining how you feel that your current internship experience contributes to your professional development. 11

12 INTERN S WEEKLY LOG BOOK (SAMPLE PAGE) Name Student ID# *Please Type and Retain a Copy Week of to,20 Example: Monday 8:00am 4:00pm 7 Hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday Start Time End Time Daily Total Total Hours II. Field experience location: 12

13 III. Evaluation of week s experiences: A. A concise description of what you did this week. B. New experiences: C. Skills and knowledge used: D. Skills and knowledge areas in which you felt deficient: E. Comments concerning your feelings and experiences: F. Plans for improving your performance: G. Situations you observed during the week that were interesting and/or beneficial to your pre-professional development: 13

14 Intern s Name: MID-TERM PERFORMANCE APPRAISAL (DUE AT MID-POINT OF PLACEMENT) Organization: Signature: Evaluator: Date: Have the results of this assessment been shared with the intern? YES NO Scale: Outstanding Very Good Average Marginal Unsatisfactory Not applicable NA 1. Communication Skills: Written Expression Oral Expression 2. Ability/Willingness to Work Independently 3. Dependability 4. Quality of Work 14

15 5. Quantity of Work 6. Interpersonal Relations 7. Ability/Willingness to Learn 8. Acceptance of Criticism and Suggestions 9. Organization/Planning Skills Major Strengths of the Student: Areas Needing Improvement: Overall Assessment (please check): Pass Not Pass Please return the completed form to: Undergraduate Internship Program Department of Kinesiology University of Windsor Windsor, ON N9B 3P4 Phone: (519) FAX: (519)

16 END OF TERM PERFORMANCE APPRAISAL (DUE AT THE END OF THE PLACEMENT) Intern s Name: Organization: Signature: Evaluator: Date: Have the results of this assessment been shared with the intern? YES NO Scale: Outstanding Very Good Average Marginal Unsatisfactory Not applicable NA 1. Communication Skills: Written Expression Oral Expression 2. Ability/Willingness to Work Independently 3. Dependability 4. Quality of Work 16

17 5. Quantity of Work 6. Interpersonal Relations 7. Ability/Willingness to Learn 8. Acceptance of Criticism and Suggestions 9. Organization/Planning Skills Major Strengths of the Student: Areas Needing Improvement: Overall Assessment (please check): Pass Not Pass Please return the completed form to: Undergraduate Internship Program Department of Kinesiology University of Windsor Windsor, ON N9B 3P4 Phone: (519) FAX: (519)

18 GUIDELINES FOR PREPARING THE FINAL REPORT NOTE: The Final Report must be typed (double-spaced) and a copy fined no later than two weeks following the completion of your internship experience. Please include the following four sections: I. AGENCY, NAME OF AGENCY SUPERVISOR, AND DATE II. SUMMARY: A brief description of your internship experience. III. IMPACT: What did you learn about yourself? In what areas did you experience the most professional growth? What insights have you gained into the field of Undergraduate? Based on your internship experience, what skills would you like to develop in preparation for our career? How has the internship influenced your career goals? Please explain. IV. EVALUATION Did the internship experience meet your personal expectations? How would you assess your performance at the agency? Would you recommend this site to future interns? 18

19 EVALUATION OF THE AGENCY Instructions: Please rate the strengths and weaknesses of the agency in terms of meeting your needs as an intern. Use the following scale: Excellent More than Adequate Less than Poor Not Adequate adequate applicable NA ITEM SCORE 1. Accepted you as a functional member of the agency staff. 2. Provided you with relevant experiences in administration, supervision and leadership. 3. Provided you with professional growth experiences (e.g., training programs, seminars, other developmental activities. 4. Provided assistance to you meet your personal and professional goals and objectives. 5. Possessed the resources essential to the preparation of Undergraduate professionals (library, equipment, supplies, etc.). 6. Provided you with the opportunity to dialogue with other professionals. 7. Provided you with sufficient feedback on your performance. 8. Allowed you the opportunity to test classroom theory in applied situations. 9. Willing to listen to your suggestions or recommendations and discussed rationale for acceptance or rejection. Additional Comments (attach an additional sheet): 19

20 EVALUATION OF THE AGENCY SUPERVISOR Instructions: Please rate the quality of supervision you received by your agency supervisor during the internship. Use the following scale: Excellent More than Adequate Less than Poor Not Adequate adequate applicable NA ITEM SCORE 1. Interested in your development. 2. Willingness to discuss the full range of activities at the agency. 3. Ability to respond to your problems and to help you work toward solutions. 4. Quality of conferences with agency supervisor. 5. Adequacy of arrangements made to orient you to the agency. 6. Sensitivity to your needs in accomplishing your objectives. 7. Expression of encouragement and sincerity. 8. Understanding of philosophy and practices in the profession. 9. Flexibility in arranging your task in light of changing situations within the agency and you re increasing professional competencies. 10. Openness to change, innovation, and new techniques. Additional Comments use other side if necessary: k:kin/undergrad/95-498_internship_program 20

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