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APPIC APPLICATION FOR PSYCHOLOGY INTERNSHIP (AAPI)
2006-2007

PART 2
Academic Program’s Verification of Internship Eligibility and Readiness

NOTE:  This form is to be completed and submitted separately from Part 1 of the AAPI.

Instructions to the Applicant:  In consultation with your graduate school training director, please complete questions 1 - 7 on your word processor.  Please do not complete questions 8 - 16.  You should then print out a copy of this form and provide it to your graduate school training director along with instructions about how this form is to be submitted to internship sites (some sites’ materials will describe their requirements for submission).  It is acceptable to APPIC to submit photocopies of this form with the signature photocopied.  However, please consult the application instructions for each site for more information, in the event that this is not acceptable to a specific site.

Instructions to the Training Director:  It is your responsibility to ensure that the information on this form is accurate.  Please review and verify the information filled in by the applicant for questions 1 - 7 (and correct it, if necessary), complete questions 8 - 15, and sign and date this form.  This form may either:  (a) be sent directly to the internship site by you, or (b) be returned to the applicant (to be sent to the internship site by the applicant along with the AAPI and any other application materials).  It is acceptable to APPIC to submit photocopies of this form with the signature photocopied.  The applicant should consult the application instructions for each site for more information in the event that this is not acceptable to a specific site. It is their responsibility to inform you of any exceptions.

applicant information
1.  Applicant’s Name: |

2.  Doctoral Program / Department:

Doctoral Program in Clinical Psychology
Department of Psychology

3.  University / School: | University of Saskatchewan
4.  Director of Training: | Margaret Crossley, Ph.D.
5.  Director of Training’s Street Address: | 9 Campus Drive
City: | Saskatoon
State/Zip | SK
Phone: | (306) 966-5923
E-Mail: | margaret.crossley@usask.ca

6.	Academic Requirements:  It is understood that many applicants may still have comprehensive exams to complete prior to February 1, 2007 and coursework to complete prior to June 30, 2007.  Please enter the dates that the following items were completed.  Also, please list any requirements, as of today’s date, that must still be completed before the student will be ready to go on internship, along with the expected date of completion.

	In Column 1, enter the date completed or the expected completion date in mm/yyyy format.  If not applicable, instead enter “Not Applicable.”

	In Column 2, indicate with a “Yes” or “No” if the completion of the task is required by your program for a student to be able to accept an internship.

	In Column 3, indicate with a “Yes” or “No” if the completion of the task is required by your program for a student to be able to attend an internship.

ACADEMIC REQUIREMENTS
| Column 1 | Column 2 | Column 3
| Date Completed  or Expected (mm / yyyy) | Required to accept an  internship? | Required to attend an  internship?
a.	Comprehensive / Qualifying Exam / Task | / | ☒Yes  ☐No | ☒Yes  ☐No

b.	Academic Coursework			
(excluding dissertation and
 internship hours if applicable)

/

☒Yes  ☐No

☒Yes  ☐No

c.  Master’s Thesis | / | ☐Yes  ☒No | ☐Yes  ☒No
d.	Dissertation / Doctoral Research Project | | |
Proposal approved | / | ☒Yes  ☐No | ☒Yes  ☐No
Data collected | / | ☐Yes  ☒No | ☐Yes  ☒No
Data analyzed | / | ☐Yes  ☒No | ☐Yes  ☒No
Defended | / | ☐Yes  ☒No | ☐Yes  ☒No
Comments:

7.	Practicum Hours:  The above-named applicant has completed the following practicum hours as of November 1, 2006 (the hours listed below should be identical to the hours listed in the “Doctoral through Nov. 1, 2006” column ” (in Section 3 of the AAPI, item 4) 

PRACTICUM HOURS information
Doctoral Hours through Nov. 1, 2006
a.	Total Intervention and Assessment Hours (item 1): |
b.	Total Supervision Hours (item 2): |
c.	Total Support Hours (item 3): |

8. The student has described anticipating the following additional practicum experience prior to the start of the internship. (This summary should match what was presented on part 1 of the AAPI)

     

	a. I verify that plans are in place for this student to obtain this anticipated practicum experience   ☐Yes    ☐No
 
9.	Academic Standing: Please answer the following questions regarding the above named student’s academic standing. This item is to be completed by the Training Director.

academic standing
a. Is this student in good standing? | ☒Yes   ☐No
If no, please explain:
b. Is this student currently on probation? | ☐Yes   ☒No
If yes, please explain:
c. Are any complaints currently pending against this student or were any filed in the past and found to be legitimate? | ☐Yes   ☒No
If yes, please explain:

10.	What is the student’s designated subfield of his or her doctorate in Psychology? (Please Check) This item is to be completed by the Training Director.
Designated subfield for doctorate in psychology
☐Clinical Adult Track | ☐Counseling | ☐Health
☐Clinical Child Track | ☐School | ☐Combined
☐Clinical General Track | ☐Neuropsychology | ☐Respecialization
☐Other: | Specify if Combined:
If “Other”, please explain why this student is applying for an internship.
	     

11.	Department’s Training Model: (Please check)  This item is to be completed by the Training Director.

Department’s Training Model
☐  Clinical Scientist | ☐  Practitioner-Scholar
☒  Scientist-Practitioner | ☐  Practitioner

☐  Other - specify:       
(e.g. Developmental, Specialty, Local Clinical Scientist)

12.	APA / CPA Accreditation:  (Please check)  This item is to be completed by the Training Director.
Accreditation Status
☒ Accredited
☐ Accredited, on Probation
☐ Not Accredited

13.	Has this student ever reneged on an APPIC internship match agreement (i.e., refused to attend or left an internship program that was obtained through the APPIC Match or Clearinghouse) without prior approval from APPIC and the internship site?  This item is to be completed by the Training Director.

	☐Yes	☒No

	If yes, please explain:
     

14.	Evaluation of Applicant: Please answer the following statements.  If you do not have sufficient information to rate the applicant, please check with other faculty, supervisors, etc. in order to complete this section.  This item is to be completed by the Training Director.

EVALUATION OF APPLICANT
a)  This applicant has possessed the emotional stability and maturity to handle the challenges of graduate training to this point. | ☐Yes	☐No
b)  This applicant possesses the theoretical / academic necessary foundation for effective counseling / clinical work. | ☐Yes	☐No
c)  This applicant possesses the skills necessary for translating theory into integrated practice. | ☐Yes	☐No
d)  This applicant demonstrates awareness of, and practices according to, the current ethical guidelines for psychologists. | ☐Yes	☐No
e)  This applicant demonstrates the capacity to participate in supervision constructively and can modify his / her behavior in response to feedback. | ☐Yes	☐No
	
 15.	Additional comments:  Please identify areas of particular strength and areas of potential further development while on internship. If you do not have direct knowledge of this student, please gather the appropriate information from relevant parties. This item must be completed by the Training Director. (If you are referring to an attached letter, please be sure that the letter addresses particular strengths and areas in which the student needs further development.) 
     

16.	The faculty agrees that this student is ready to apply for internship.  (Please check)  This item is to be completed by the Training Director.

	☐Yes	☐No

	If no, please explain:        

17.	Once the student is on internship:  Who will serve as the contact person between your department and the internship program?  (e.g., Training Director, Academic Advisor)   This item is to be completed by the Training Director.

Name: | Margaret Crossley, Ph.D.
Street: | Dept of Psychology, 9 Campus Drive

City/State/Zip

University of Saskatchewan
Saskatoon, SK  S7N 5A5 Canada

Phone: | (306) 966-5923
E-Mail: | margaret.crossley@usask.ca

Signature of the Director of Training: _____________________________________________
or Electronic (Typed & Must be emailed from their email account):       

Date signed:

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