Health and Fitness Management Internship Form : Department of Health and Human Performance : Texas State University

Name of Agency: *

Name & Title of Preceptor. *

Person overseeing 400-hour internship.

Qualification of perceptor *

Include certifications and licenses

Telephone Number *

Email *

Facility Address *

Number of years in agency in operation. *

Agency hours of operation. *

What is the mission or purpose of the agency? *

Does the agency have an up-to-date policy and procedure manual, including eergency procedures? *

Yes

No

Facility Equipment: List equipment/amenities/services/and any additional information about your facility. *

Total # of employees in unit where intern will be assigned. *

Number of interns that will be on site during this placement term. *

Have interns been placed here before? *

Yes

No

Anticipated itern duties and responsibilities. *

Anticipated intern work schedule. *

(Approximately 30-40 hours per week)