Internship Non Supervised Experience PROPOSAL FORM Section One Information by epmd


									             Internship & Non-Supervised Experience PROPOSAL FORM
Section One: Information for Preservice Educators
  To complete this Proposal for Professional Experience you must be enrolled in a professional experience
course in web or external mode only. You will need to seek approval to undertake the professional
experience from the site-based coordinator who may be the Principal, Deputy Principal, Director or
Coordinator at the educational setting.
   It is the preservice educator’s responsibility to ensure that this form is completed and submitted by the
required date for each course.
   Approved placements will be confirmed for the preservice educator at

Section Two: To be completed by the Preservice Educator
Student Number                                     Contact phone number
Campus                                             Program
Email Address
Course                                             # of professional experience
                                                   days proposed
Previous professional experience sites                     Year level/ age group/ teaching areas

Name of the Educational setting proposed for
Professional Experience:

Proposed Dates:
Proposed Project Area: (if determined)

Conflict of interest: I do/ do not have a conflict of interest with this site. If yes, please attach additional form
available at: )
Legal requirements:
Queensland setting: You are required to have a current Working with Children Suitability card registered
with the Faculty of Education.
Qld suitability Card #                                                  Expiry date     /    /

Signed (by USQ preservice educator)                                            Date

In a Non-Queensland setting you are required to have checked the legal requirements with your
educational setting and you need to attach to this form a copy of the legal documentation.

 I have attached an academic transcript of my results to date and confirm I am eligible to proceed on to my
Internship/non-supervised experience

I acknowledge that I have read and accept the requirements of professional experience arrangements in this
proposal and I have read the professional experience requirements for this placement.

Signed (by USQ preservice educator)                                            Date

Internship & non supervised Proposal Form 2009
Section Three – Approval Agreement for placement at the site
To be completed by the Principal; Deputy Principal or Site Coordinator.
Information for proposed setting
   Preservice Educators must have access to qualified and experienced Mentors and to a Coordinator who
will arrange for the Preservice Educators to be observed, receive feedback and to be assessed over the
period of the professional experience.
   A handbook outlining the requirements of the professional experience including evaluation will be
provided to the setting by the Professional Experience Support office once a proposal is approved
   Mentors and Coordinators supervising assessed professional experience may be eligible for payment
under the Practice Teaching in State Schools Industrial Agreement. Details will be provided once the
placement is confirmed. Please note that where a preservice educator is employed during professional
experience at the site, payment may not occur.

School or College
Site Coordinator’s Name:
Mailing Address

Phone Contact:
Placement details for this proposal
Mentoring Teacher/s                         Teaching Area                            Year level/stages
                                            (TVE/Snr/Middle only)

I hereby confirm that …………………………………………. will be able to fulfill the Internship/non supervised
                          (USQ Preservice Educator’s name)
experience requirements as outlined by the Preservice Educator.

Is this Preservice Educator an employee of your educational setting?             YES/NO

Signed                                                                       Date:
Confirmed placement details will be available at

Toowoomba Campus                            Fraser Coast Campus                  Springfield Campus
Mail -Professional Experience               Mail -Professional Experience        Mail -Professional Experience
Support Office Faculty of                   Support Office Faculty of            Support Office Faculty of
Education- University of Southern           Education- University of Southern    Education- University of Southern
Queensland Toowoomba Qld                    Queensland PO Box 910 Hervey         Queensland Toowoomba Qld
4350 Fax- 07 4631 2598                      Bay Qld 4655 Fax- 07 4194 3188       4350 Fax- 07 4631 2598
Scan & email-                               Scan & email-                        Scan & email-                 

USQ Use Only
   Sector confirmation checked (if req)                               Secondary Teaching areas checked (if req)
This proposal is:        Approved / Not Approved
USQ Coordinator/                                                    Date:
Course Examiner

Internship & non-supervised Proposal form 2009

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