| Student Intern's Name: |
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| Please enter today's date: |
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| Report number: |
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| Communication with supervisor: |
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| Physical well being (food, lodging, general health): |
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| Opportunity to learn and practice skills: |
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| Your level of satisfaction with this experience so far: |
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Assumed level of satisfaction of the experience provider:
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| Cooperation with fellow workers: |
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| Please rate your work speed: |
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| Please tell me your level of ability to handle responsibility: |
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| How are you handling suggestions from supervisors? |
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| What level of technical competence have you achieved? |
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| In the following boxes, please list jobs or duties you have been performing. Indicate how many hours you have spent on each job, and what level of proficiency you have achieved: |
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| Additional job or duty: |
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| Additional job or duty: |
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| Are you keeping a daily journal of your experiences? |
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Please enter the number of hours worked during this report period:
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| Please indicate number of hours/days absent from duty, and explain reason for absence. Please remember to clear any absence with your supervisor, and the department coordinator. |
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| Firm name and address: |
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| Owner/Supervisor name: |
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| Phone number: |
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| Your preferred email address (not the employers): |
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| Initial: |
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