Human Services Program PRACTICUM HOURS REPORT Student Name: Total Term: Credits Required F W SP SU (circle one) Year: Registered: Hours: Agency Name: Supervisor’s Name Month: Total Daily Total Daily Total Daily Day Day Day Hours Hours Hours 1 11 21 2 12 22 3 13 23 4 14 24 5 15 25 6 16 26 7 17 27 8 18 28 9 19 29 10 20 30 31 Monthly Total: Total Hours To Date: Per student signature, the hours listed on this record are true and correct: Student’s Signature: Date: Supervisor’s Signature: Date
Human Services Program PRACTICUM HOURS REPORT Student Name: Term: (circle one) F W SP SU Year: Credits Registered: Total Required Hours: Agency Name: Supervisor’s Name Month: Day Total Daily Hours Day Total Daily Hours Day Total Daily Hours 1 11 21 2 12 22 3 13 23 4 14 24 5 15 25 6 16 26 7 17 27 8 18 28 9 19 29 10 20 30 31 Monthly Total: Total Hours To Date: Per student signature, the hours listed on this record are true and correct: Student’s Signature: Date: Supervisor’s Signature: Date
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