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This form is to be signed by your site supervisor and returned to the instructor for verification. It will then be placed in your permanent file.

Name___________________________________________SSN#___________________________

Address_________________________________________________________________________

_______________________________________________________________________________

Home Phone:____________________________ Work Phone ______________________________

Applied Practices II Completed: Fall_______________ Spring__________________

This is to certify that as of _____________, 20_______ the above named student has completed _______total hours of experience under my supervision at:

Site Name:_______________________________________________________________________

Address_________________________________________________________________________

_______________________________________________________________________________

Site Phone_________________________________________

Signature of Site Supervisor_________________________________________________________

Please Print/Type Site Supervisor Name________________________________________________

Supervision during this field placement has been provided as follows:

________ Individual supervision hours provided by Site Supervisor

________ Group meeting supervision hours provided on-campus

________ Individual supervision hours provided by Marywood Faculty

The accuracy of the reported information has been verified though student contact and an examination of the student's weekly activity logs.

Faculty Supervisor____________________________ Date:_______________________________