ProjectCourse Application –IPL 301

  1. The student should complete this form AFTER identifying his/her project. (The same process applies for online students.)
  2. Once completed, the student should have the field supervisor (supervisor of the project work) sign on page 4.
  3. Once the field supervisor has signed, the student should obtain department approval with a signature on page 4.
  4. Submit thecompleted form to IPL in Brookens 482 or y the first week of the semester; upon approval, the student will receive an email regarding course approval to register for the Projectcourse, IPL 301.

ProjectSemester/Year: ☐Spring 20____ ☐Summer 20____ ☐Fall 20____

STUDENT INFORMATION

Student Name: ______University ID Number: ______

Phone: ______UIS Email Address: ______

Academic Program/Major: ______Academic Advisor: ______

Expected Graduation Date: ______☐Are you an international student? ☐Are you receiving military benefits?

PROJECT FOCUS INFORMATION

Field Supervisor's Name: ______Title: ______

Phone: ______E-Mail: ______

Field Supervisor’s Affiliation (Department/Organization/Company): ______

Address: ______City: ______State: ____ Zip Code: ______Country: ______

Is the work for thisProject ☐ PAID ☐ UNPAID?

Fifty (50) hours of work must be completed for each credit.

Total semester credit hours: ______x 50 = ______Minimum number of hours to be worked

All internships must be at least8 weeks in length. Fifteen (15) weeks is average for fall and spring semesters.

Beginning Date: ______Ending Date: ______Average number of hours per week: ______How will you use this credit (consult with your advisor if needed)?

ECCE Engagement or ECCE Elective? Number of Credits ______

General Electives? Number of Credits ______

University Requirement (pre-2007 catalog)? Number of Credits ______

Attach a separate sheet of paper that provides a detailed project proposal. Address each of the questions below.

  1. Describe the proposed project. Describe the end product. Will it be patented/published? Include the process in your plans.
  2. If applicable, discuss the prototype for possible publication.
  3. Provide a timetable of the tentative stages of development & completion.
  4. Briefly discuss how the project will proceed, including the perceived roles of Field Supervisor and UIS Supervisor. Include how often and how you will meet with the Field Supervisor. You must meet with your Field Supervisor at least once each week during the semester either in person/telephone/video conference to receive assistance, next step guidance, or encouragement; answer and ask questions and maintain quality control.
  5. Is this Project being done at your place of current employment? ☐ Yes ☐ No
  6. If yes, define how this project significantly differs from your previous/regular duties.
  7. How many hours each week will be devoted to the new experiences?
  8. What do you want to accomplish and learn from this experience? Briefly, list at least 5 or 6 objectives. These are tentative objectives. Consider that you might explore or confirm a career choice, develop a better understanding of the value of diversity, identify social issues, develop and apply leadership skills, engage with the community where you are living/visiting, apply academic and disciplinary knowledge.
  9. List the academic coursework, experiences, and/or skills you have that will be an asset in your proposed Project.

STUDENT SIGNATURE

As a currently enrolled UIS student and by signing this contract, I understand (PLEASE INITIAL EACH STATEMENT):

In order to earn academic credit I must:

______Participate in the onlineclass held during the semester.

______Stay up-to-date on assignments and project work based on due dates I set at the beginning of the semester.

______Keep a reflective journal of every day I work on the project. Hours not recorded in the journal do not count towards my total.

______Create a learning contract that includes learning objectives, the activities/experiences that will be done to achieve them, and the methods for evaluating achievement.

______Schedule and participate in a site visit with the Field Supervisor and UIS Supervisor.

______Contact my course instructor immediately if I start to fall behind or have questions.

______If completing a project for more than 6 credit hours, I must complete additional course requirements.

If I am working with an external organization/supervisor, as an ethical representative of UIS, I will:

______Dress appropriately for the work place as defined by the employer’s dress code.

______Demonstrate respect, dependability, and cooperation with my supervisor and co-workers.

______Ask questions to identify/clarify any confusion regarding my project responsibilities.

______Maintain a strictly professional relationship with my supervisor and co-workers.

______Refrain from the consumption of alcohol and/or drugs while completing my project.

______Adhere to organizational policies, including confidentiality of personnel, projects, and research.

______Strive to understand what constitutes a permissible work absence and who to notify if absent.

______Report changes in schedule, supervision, or problems to my UIS supervisor.

______RELEASE: In consideration of being permitted to participate in the above-noted placement as a Project (AST), in full recognition and appreciation of the dangers inherent in participation in said placement and related activities, do hereby agree to assume all risks and responsibilities surrounding participation in the above-noted placement and activities undertaken as an adjunct thereto; and further, I do for myself, my legal representatives, my heirs and assigns, agree to defend, hold harmless and indemnify, and hereby release and forever discharge the Board of Trustees of the University of Illinois and the University of Illinois at Springfield, their officers, agents and employees, from any and all claims, demands, actions or causes of action arising from or by reason of any bodily injury or personal injury, known or unknown, death or damage to personal property resulting from any accident which may occur as a result of participation in said placement and activities adjunct thereto, whether by negligence or not. Further I state that I have carefully read this Release and know and understand its contents and sign this Release as my own free and voluntary act.

______For International Students working for an external organization: As an international student, I must be approved for Curricular Practical Training (CPT) by the ISS office at UIS prior to beginning the Project experience. I must also submit the employer’s offer letter, which states expected work load (number of hours per week not to exceed 20 per week during regular semesters and 40 hours per week during summers) and start and end dates to the ISS office and IPL office. I am only allowed to participate in a maximum of two internship/Project experiences, and only under extraordinary circumstances. Thus, only two CPT authorizations, which cannot total one year of full time CPT.

I have fully read, understand, and agree to all of the above statements:

STUDENT SIGNATURE:______DATE:______

Printed Name: ______

FIELD (PROJECT)SUPERVISOR APPROVAL

As a Project Field Supervisor for a UIS Student, I understand (PLEASE INITIAL EACH STATEMENT):

______I have reviewed students’ qualifications, selected a student, and assigned projects in accordance with federal, state, and local laws (e.g., race, sex, national origin, religion, age, disability, etc.).

______I agree to act as a Field Supervisor responsible for the mentorship of the student during the completion of the described project. I also agree to discuss the student’s work with him/her and to provide feedback and suggestions as necessary.

______I agree to report any changes, concerns, or questions I may have regarding the student or project experience directly to the Internships and Prior Learning Office.

______I agree that my relationship with the student will remain professional at all times.

______I agree to provide performance feedback to my student throughout the project experience.

______I will participate in a site visit or phone conference with the student and the student’s UIS supervisor about halfway through the project work.

______I should complete aField Supervisor Evaluationnear the end of the academic semester for which the student is registered (UIS does not expect disclosure of proprietary company information).

______Neither a relative of the student nor a current UIS student can serve as supervisor without prior approval by the IPLCoordinator.

REQUIRED SIGNATURE. I have fully read, understand, and agree to all of the above statements:

Printed Name: ______Signature:______Date:______

UIS DEPARTMENT/SUPERVISOR APPROVAL

The STUDENT must have a faculty member* in his/her department endorse this project.

*Students in the following degree programs should have the faculty member listed approve/sign this form.

Computer Science: Dr. Ted Mims ()

Psychology: Dr. Sheryl Reminger ()

Other departments: Identify your faculty advisor or a faculty member with whom you have taken courses or worked. Contact the IPL Office if you have questions about who to contact.

DEPARTMENT SIGNATURE

I agree that this student should complete the project, as presented on his/her projectapplication, for his/her degree progress.

Printed Name: ______Signature:______Date:______

Please indicate whether or not you agree to be the UIS supervisor for this student's experience♦: _____YES_____NO

♦The Computer Science and CCJ Departments assign a UIS supervisor.

The UIS Supervisor has three duties:

  1. To make one “site visit” (can be a conference call). The student is responsible for scheduling the site visit at a time convenient for all. This should be done when no more than 40 to 50 percent of the clock hours have been completed.
  2. To review and endorse the student's Learning Contract at or immediately after the time of the site visit.
  3. To review and assess the completed project materials and recommend awarding credit (or not).

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