Independent Practicum Info Sheet
For Independent Practicum, Practicum Project, Directed Studies, Client Projects and other credit-bearing work involving organizations outside of MIIS. This information is for MIIS internal use only.
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First Name *
Last Name *
Permanent Email (Non-MIIS) *
Current Semester *
Organization (if applicable) *
 Job Title or Title of Project *
Description of Job or Project (Optional)
City *
State or Country *
Street Address (Optional)
Supervisor's Name (if Project, Faculty Advisor's Name) *
Supervisor's Email Address *
Supervisor's Phone Number (Optional)
What are/were the approximate dates of your independent practicum? *
How many hours a week are you working/did you work on average? (Optional)
Are you paid? (Optional)
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