Student Name Student Year Student Signature Date

The mandatory pro bono requirement for graduation is to do 50 hours of law related public service work, not including time in training, travel, or observation. For summer positions, hours may be recorded by each week, rather than day.

Please discuss expectations about time keeping with your supervisor at the beginning of your pro bono project – some supervisors may expect you to be more precise than others in your time keeping. If you are already recording hours in a similar format on another form for your organization, you may return a photocopy of that to us in lieu of this form. Thank you for your cooperation in recording hours!

I certify that the pro bono hours indicated above are accurate and request that these hours be counted toward the pro bono requirement.

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Student Name Student Year Student Signature Date

1. Name of Placement Organization:

2. Organization Address

Street Address

City State Zip

3. Phone ()- Fax () - Email:

4. Date placement began / / Date placement ended / /

5. Did you provide monetary compensation to the student while he or she was fulfilling the pro bono requirement?

Yes No If yes, specify amount and source:

6. Did the student complete theassigned tasks in a timely manner? Yes No

7. Did the student perform in a professionally responsible manner? Yes No

8. What was most beneficial for your organization about this experience?

9. Would you supervise another HLS student in the Pro Bono Service Program? Yes No

10. Do you have any comments or suggestions concerning the Pro Bono Service Program?

I certify that, under my supervision, (write in student name)

has satisfactorily completed (#)pro bono hours as indicated on the Student Time Log.

Supervisor NameSupervisor Title

/ /

Supervisor SignatureDate(MM/DD/YYYY)

This form should be filed within 10 days of the student’s completion of his or her pro bono work. For third year students, it shall be submitted no later than the Friday before spring recess. STUDENTS WILL NOT RECEIVE CREDIT TOWARDS THE PRO BONO REQUIREMENT OR THE PUBLIC SERVICE INITIATIVE UNTIL THIS FORM HAS BEEN SUBMITTED.

The form may be mailed, faxed, or emailed to the Pro Bono office. To execute this form electronically (via email), sign with an electronic signature or print your name above the signature line along with the words “electronic signature” and email the form to the email address below using your official (work or school) email address. Please call our office at 617-495-5202 with any questions.You may give this completed form to the student to submit, or send to the following address:

Return to:Office of Clinical and Pro BonoPrograms

Harvard Law School, WCC 3085

6 Everett Street

Cambridge, MA 02138

Fax: (617) 496-2636 Email:

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