HMSV Internship Site and Supervisor Qualification Form

Name of HMSV intern Name of HMSV intern * First Last
ODU Email *
Internship semester *

Internship semester Fall 2023 Spring 2024 Summer 2024 Fall 2024 Spring 2025 Summer 2025 Fall 2025
Site location *

Site location Main Campus Distance Learning- Online
Internship Information
Agency/ Site *
Department/ Program
Supervisor Name Supervisor Name * First Last
Supervisor job title *
Supervisor Phone Supervisor Phone * - ### - ### ####
Supervisor Email *
Agency/ Site Address Agency/ Site Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Supervisor licensure information

(if applicable)
Type of license
State & department issuing license
License number
Expiration date
Supervisor educational/academic information

*If the highest degree earned is a bachelor's level degree, then a current copy of the supervisor's resume must be submitted with this form. Remember that supervisors must have at least 5 years of experience in the field if the highest degree earned is bachelor's level.
Highest degree earned *
Major/ program of study *
Number of years experience in HMSV field *
Upload Site and Supervisor Paperwork (Must upload entire Internship Agreement Form!)

To upload as a PDF- you may scan in your document and use a converter on your computer, OR use a free phone app (such as Notes or Genius Scan) to snap pics of each page from your phone, then send the pdf to yourself so that you may download then attach that here.
Upload a File: Supervisor's resume (only needed to show 5+ years experience if supervisor has a bachelor's degree)

Attach Files
Upload a File: Internship Agreement Form *

Attach Files
Download Internship Agreement Form
I have completed the modules in the Internship Organization in Canvas *

I have completed the modules in the Internship Organization in Canvas Yes
I completed the Exit quiz in the Internship Organization in Canvas, with a score of at least 7/10. *

I completed the Exit quiz in the Internship Organization in Canvas, with a score of at least 7/10. Yes

HMSV Internship Site and Supervisor Qualification Form

Internship Information

Supervisor licensure information

Supervisor educational/academic information

Upload Site and Supervisor Paperwork (Must upload entire Internship Agreement Form!)

Download Internship Agreement Form