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Quick Guide to Pre-Internship Forms

Here is a quick guide to the various forms and requirements for Practicum. PLEASE READ CAREFULLY.

  1. Checklist – list of LVC requirements for Internships – LVC ONLY REQUIRES THOSE HIGHLIGHTED. If the site does not require all health and background checks, students may not need to complete them - ASK THE SITE.
  2. Internship REGISTRATION Form – required by all students for internship registration, Faculty Internship Coordinator (FIC) completes and submits, including a signature of Advisor, (FIC), and Department Chair.
    • must submit site supervisor name, e-mail, phone #, Site name, and Address
  3. EXSC Confidentiality Pledge/Informed Consent/Conflict of Interest – required by all students.
  4. EXSC Career Plan – optional - useful for students who are unsure of their future career path
  5. EXSC Student DATA Sheet – required by all students. Goals for the Internship must be objective and measureable. Review course objectives included in the Syllabus
  6. Medical History Form – Use this form if the site requires a Physical Exam but does not provide a specific form. Physical must be signed by a recognized health care professional such as a nurse, physician, physician assistant, etc.
  7. TB Test Documentation – Use this form if the sire requires a 1- or 2-step test. Complete only if the site requires it.
  8. PA Child Abuse Clearance Instructions – Complete only if the site requires a Child abuse clearance AND YOU ARE A RESIDENT OF, OR CURRENTLY RESIDE IN PA. If you reside in another state, please follow your state guidelines for all background checks.
  9. PATCH Instructions – Complete only if the site requires a Criminal Record Check AND YOU ARE A RESIDENT OF, OR CURRENTLY RESIDE IN PA. If you reside in another state, please follow your state guidelines for all background checks. 
  10. FBI Criminal History Record Instructions - Complete only if the site requires Finger Prints, which are federal clearances and the same in all states.
  11. HIPAA and OSHA Training Instruction – HIPAA and OSHA training are required by all students. Information about HIPAA and OSHA is provided in Modules. The quizzes can be found in ‘Quizzes’. You must achieve a score of 80%; unlimited attempts.