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ICC Internship Completion Check

If you experience any difficulties in completing your 160 hours for your ICC Internship, please email Jackie Lopez (ilope@gse.upenn.edu/

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SITE SUPERVISOR VERIFICATION

I verify that the information in the Hours Log is accurate and that this student has completed a minimum of 160 hours at the
organization.

Site Supervisor Signature (not typed) Date

Site Supervisor: Please include your position title and contact information below:

SITE SUPERVISOR NAME: -...--'"'-"-----'-------------

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POSITION TITLE: J . , , /LAI ""' . ..-1 r t.L-J u,..__

Email: -- - . , ..

Phone Number:--=-----=-----------

ICC Student: Once the Hours Log is completed, verified, and signed by your site supervisor, please email Jackie Lopez a,ope@gse.upenn.edu} an electronic copy.
When approved by Jackie, she will notify Sarah Peyton Kaufman, Program Manager, so you can obtain a course permit to register for EDUC 567: ICC Internship course.

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ICC Internship Completion Check

If you experience any difficulties in completing your 160 hours for your ICC Internship, please email Jackie Lopez (iiope@gse.upenn.edu)

ICC Student Name: Internship Site Name: __;_..:...\

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**Please be as detailed as possible with your Hours Log or keep separate detailed notes. Do not write your hours in one box but please log
your hours over time (see sample on page 3). This will not only help us determine that you completed your 160 hours but it will also help you later on
when you take EDUC 567. You may print this page multiple times.**

Date Duties/Responsibilities Completed: Reflection & Analysis: Hours

Completed

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